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Digitized  by  tine  Internet  Archive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/treatiseondiseas1888sken 


TREATISE  ON  THE 


DISEASES  OF  WOMEN 


FOR  THE  USE   OF 
STUDENTS  AND   PEACTITIONERS 


BY 

ALEXANDEE  J.   C.   SKENE.  M.  D. 

PROFESSOR  OF  GYNECOLOGY  IN  THE  LONG  ISLAND  COLLEGE  HOSPITAL,  BROOKLYN,  NEW  YORK 

FORMERLY  PROFESSOR  OF  GYNECOLOGY  IN    THE    NEW  YORK    POST-GRADUATE    MEDICAL    SCHOOL 

GYNECOLOGIST  TO  THE  LONG  ISLAND  COLLEGE  HOSPITAL 

PRESIDENT  OP  THE  AMERICAN  GYNECOLOGICAL  SOCIETY,  188T 

CORRESPONDING  MEMBER  OF  THE  BRITISH,   BOSTON,   AND  DETROIT  GYNECOLOGICAL  SOCIETIES 

FELLOW  OF  THE  NEW  YORK  ACADEMY  OF  MEDICINE 

EX-PRESIDENT  OF  THE  MEDICAL  SOCIETY  OF  THE  COUNTY  OP  KINGS 

EX-PRESIDENT  OF  THE  NEW  YORK  OBSTETRICAL  SOCIETY 


WITH  251   ENGRA  VINGS  AND  9    CHR0M0-LITH0GRAPH8 


NEW   YORK 
D.    APPLETON    AND    COMPANY 

1888 


COPYEIGHT,  1888, 

Br  D.   APPLETON  AND  COMPANY. 


TO 
THOMAS   KEITH,   M.  D.,  LL.  D.,  F.  R.  C.  S.  E., 

THIS    WORK    IS    DEDICATED 

AS    A    TRIBUTE    TO    HIS    ACHIEVEMENTS    IN    SURGERY, 

HIS    JUSTICE    AND    COURTESY    TO    THE    MEDICAL    PROFESSION    OF    AMERICA, 

AND    AS    AN    ACKNOWLEDGMENT    OF    HIS    KINDNESS    TO    THE    AUTHOR. 


PEEFACE. 


This  book  was  written  for  the  purpose  of  bringing  together 
the  fully  matured  and  essential  facts  in  the  science  and  art  of  gyne- 
cology, so  arranged  as  to  meet  the  requirements  of  the  student  of 
medicine,  and  be  convenient  to  the  practitioner  for  reference.  In 
the  plan  adopted,  the  diseases  peculiar  to  women  are,  as  far  as 
possible,  divided  into  three  classes.  The  first  class  comprises  those 
which  occur  between  birth  and  puberty ;  the  second,  those  between 
puberty  and  the  menopause ;  and  the  third,  those  which  come  after 
the  menopause. 

Each  subject  is  briefly  described,  and  histories  of  cases,  typical 
and  complicated,  are  given  as  illustrative  of  the  disease  or  injury 
under  consideration,  together  with  the  author's  method  of  treat- 
ment. The  number  of  ilkistrative  cases  given  depends  upon  the 
practical  importance  of  the  subject  and  the  ability  to  make  it  more 
plain  by  the  use  of  illustrations. 

In  carrying  out  this  plan,  the  history  of  gynecology  and  the 
discussion  of  all  unsettled  questions  have  been  omitted,  as  being  at 
variance  with  the  plan  adopted. 

Credit  has  been  given  as  far  as  possible  to  those  who  have 
made  original  discoveries,  but  a  vast  number  of  original  workers 
have  been  passed  unnoticed  for  want  of  time  and  space  even  to 
name  them. 

To  the  medical  student,  history  has  no  value  until  he  has 
mastered  the  rudiments  of  the  science  and  the  art,  and  the  prac- 
titioner can  find  in  the  works  of  reference  all  the  historical  facts 
which  he  may  seek. 


yi  PREFACE. 

The  author  has  ventured  to  give  his  own  views  and  methods 
pertaining  to  practical  matters,  believing  that  while  thej  may  differ 
to  some  extent  from  the  general  literature  of  the  day,  they  will 
be  found  reliable  in  practice  and  may  be  of  interest  to  the  spe- 
cialist. 

Marginal  references  have  not  been  made,  because  all  selections 
from  the  literature  that  have  been  incorporated  in  this  work  are 
those  already  well  established  and  familiar  to  the  gynecologist, 
and  foot-notes  only  embarrass  the  reader  who  is  seeking  for  the 
facts  alone. 

Acknowledgments  are  due  to  my  associates  —  Dr.  J.  H.  Ray- 
mond, who  has  rendered  valuable  aid  in  the  preparation  of  the 
work,  and  Dr.  E.  L.  Dickinson,  who  has  made  the  drawings  for 
the  original   illustrations. 

The  Author. 


TABLE   OF  COT^TENTS. 


CHAPTER 

I.- 

II.- 

III.- 


-Methods  op  Observation    .  . 

-Development  of  the  Sexual  Organs       .... 

■Arrest  of  Development  and  Entire  Absence  of  Functional 
Activity — Arrest   of  Development   and    Growth   in  the 
Later  Stages  of  Evolution,  and  Consequent  Imperfection 
OF  Function  .  .  .  .  • 

IV. — Flexions  of  the  Uterus    .  .  .  • 

Y, — Diseases  of  the  External  Organs  of  Generation 
VI. — Diseases  of  the  Vagina     .... 

VIL— Injuries  to  the  Pelvic  Floor  from  Parturition  and 
Causes        ...... 

VIII.— Fistula  in  Ano  and  Coccyodynia 
IX. — Inflammatory  Affections  of  the  Uterus 
X. — Corporeal  Endometritis     .... 

XL — Subinvolution  ..... 

Xll. — Sclerosis  of  the  Uterus    .... 

XIII. — Membranous  Dysmenorrhcea 

XIV.— Lacerations  of  the  Cervix  Uteri  from  Parturition 
XV. — Cicatrices  of  the  Cervix  Uteri  and  Vagina   . 
XVI. — Inversion  of  the  Uterus   .... 

XVII. — Dislocations  of  the  Uterus 
XVIII. — Retroversion  of  the  Uterus 
XIX. — Abuse  of  Pessaries  .... 

XX. — Hypertrophy  of  the  Cervix  Uteri 
XXI. — Fibroma  of  the  Uterus     .... 

XXII. — Malignant  Disease  of  the  Uterus 
XXIII.— The  Menopause         ..... 

XXIV. — Diseases  of  the  Ovaries    .... 

XXV.— Diseases  of  the  Ovaries  (continued) 
XXVI. — Neoplasms  of  the  Ovary 
XXVIL— Cystic  Tumors  of  the  Ovaries— Symptomatology  and  Physi- 
cal Signs  .  .  .  .  • 

XXVIII.— Ovariotomy 

XXIX.— Illustrative  Cases  of  Ovarian  Neoplasms 
XXX.— Diseases  of  the  Fallopian  Tubes 
XXXI.— Pelvic  Cellulitis     ..... 
XXXII. — Pelvic  Peritonitis  .... 


PAGE 

1 

22 


30 
54 
76 
99 

112 

162 

171 

203 

214 

220 

229 

242 

259 

266 

279 

304 

334 

343 

348 

398 

422 

438 

454 

473 

488 
509 
530 
547 
555 
579 


viii  TAIJLE   OF   CONTENTS. 

CHAPTER  PAGE 

XXXIII.— Pelvic  II^matocele            ......  ."596 

XXXIV. — Diseases  of  the  Uki.vary  Groans             ....  (J09 

XXXV. — Malkormatio.vs  of  the  Bladder  anu  I'uktiira             .            .  022 

XXXVI. — Function  of  the  Hlauder              .....  647 

XXXVII. — Functional  Diseases  of  the  Hladuer    ....  653 

.XXXVIII.— Functional  Diseases  of  the  Bladder  (continued)       .           .  674 

XXXIX.-tMethods  of  Exploration  of  the  Bladder  and  Urethra      .  694 

XL. — Organic  Diseases  of  the  Bladder          ....  703 

,XLI. — Organic  Diseases  of  the  Bladder  (co.vtinued) — Treatment  of 
Cystitis — Croupous   and  Diphtheritic   Cystitis  —  Cystitis 

with  Epidermoid  Concretions    .....  736 

XLII. — Xon-Inflammatory  Diseases  of  the  Bladder    .           .           .  760 

XLIII. — Non-Inflammatory  Diseases  of  the  Bladder  (co.vtinued)      .  777 

XLIV. — Xon-Inflammatory  Diseases  of  the  Bladder  (continued)      .  793 

XLV. — Non-Inflammatory  Diseases  of  the  Bladder  (continued)      .  804 

XLVI. — Diseases  of  the  Urethra  and  Urethral  Glands       .           .  818 

XLVIl. — Organic  Diseases  of  the  Urethra  (continued)            .           .  849 

XLVI  1 1. — Organic  Diseases  of  the  Urethra  (continued)             .           .  868 

XLIX. — Diseases  of  the  Glands  of  the  Female  Urethra       .           .  879 

L. — Vesicle  and  Urethral  Fistula              ....  892 

LI. — Gynecology  as  related  to  Insanity  in  Women             .           .  929 


INDEX  TO  ILLUSTEATIOI^S. 


FIG. 

PAGE 

1.  Examining  table            ........        8 

2.  Bimanual  examination  . 

9 

3.  Sims's  speculum 

.      11 

4.  Cusco's  bivalve  speculum 

.      11 

5.  Sims's  position,  seen  from  above 

12 

6.  Nurse  holding  Sims's  speculum 

.      12 

7.  The  movements  of  the  speculum — first  movement     . 

.      13 

8.                "                   "                    — second  movement 

.      13 

9,                "                   "                    — third  movement  . 

14 

10.  Simpson's  probe             ..... 

.      14 

11.  Sims's  probe 

15 

12.  Whalebone  sound 

.      15 

13.  Jenks's  sound 

15 

14.  Skene's  curette  . 

16 

15.  Hanks's  dilator  . 

.      17 

16.  Palmer's  dilator 

.      17 

17.  Sponge  tents 

.      18 

18.  Tupelo  tents 

.      18 

18a.  Ether  inhaler   . 

.      21 

19.  Mailer's  duets    . 

.      22 

20.  Coalescence  of  ducts 

.      22 

21.  Disappearance  of  septum 

,      22 

22.  Appearance  of  fundus  and  cervix 

22 

23.  Infantile  uterus  (Winckel) 

23 

24.  Palma  plicata     . 

23 

25.  Infantile  uterus,  antero-posterior  section,  scant  invaginatioi 

1 

23 

26.  Virgin  uterus  (Sappey) — anterior  view 

24 

27.                "               "       — median  section 

24 

28.                "               "       — transverse  section     . 

24 

29.  Double  uterus  and  vagina  (Eisenmann) 

25 

30.  Uterus  unicornis  (Pole)             .... 

26 

31.  Uterus  bicornis  unicollis  (Winckel) 

. 

26 

32.  Uterus  bifundalis  unicollis  (Courty)    . 

. 

27 

33.  Uterus  duplex  (Cruveilhier) 

. 

27 

34.  Anteflexion  of  cervix — first  variety 

, 

57 

35.  Anteflexion  of  body  of  uterus — second  variety 

58 

36.  Anteflexion  of  body  anc 

.  cervix — thirc 

variety 

58 

INDEX   TO    ILLUSTRATIONS. 


PIO. 

40.  Thomas's  anteversion  pessary  .... 

41.  "  "  "       — in  vagina,  in  position 

42.  "  "  "       — on  removal    . 

43.  Graily  Hewitt's  anteversion  pessary    . 

44.  Thomas's  stem  pessary  .... 

45.  Extreme  anteflexion      .... 

46.  Skene's  soiMul  and  scarificator , 

47.  External  genitals  of  a  parous  woman  . 

48.  The  superficial  veins  of  the  perinaeum  (Savage) 

49.  External  genitals  of  a  virgin    . 

50.  Cribriform  hymen  .... 

51.  Annular  hymen  .... 

52.  Fimbriate  hymen  .... 

53.  Rectum  continuous  with  allantois  (bladder)  and  duct  of  Miiller 

(Schroeder)      ..... 

54.  The  depression  has  extended  inward  (Schroeder) 

55.  The  cloaca  is  dividing  (Schroeder) 

56.  The  perineal  body  is  completely  formed  (Schroeder) 

57.  The  upper  part  has  contracted  (Schroeder) 

58.  Spurious  hermaphroditism  (Simpson)  . 

59.  Length  of  vaginal  walls 

60.  Triangular  shape  of  the  perineal  body 

61.  Sims's  vaginal  dilator    .... 

62.  The  levator  ani  (after  Luschka) 

63.  The  muscles  of  the  pelvic  floor  (after  Hart  and  Savage) 

64.  Diagrammatic  sagittal  section  of  the  female  pelvis 

65.  Complete  laceration  of  the  perina3um  . 

66.  Sagging  of  the  pelvic  floor 

67.  Diagram  of  the  sweep  of  the  suture     . 
68-69.  Sutures  properly  and  improperly  introduced 

70.  Peaslee's  needle  .... 

71.  Skene's  tissue  forceps    .... 

72.  Emmet's  curved  scissors 

73.  Emmet's  scissors  .... 

74.  First  step  of  perineorraphy,  denudation  begun 

75.  Second  step,  continuing  the  strip 

76.  Vivifying  complete        .... 

77.  Skene's  needle-forceps  .... 

78.  Stitch  in  place    ..... 

79.  The  stitches  in  place      .... 

80.  Laceration  with  rectocele 

81.  Perineal  body  restored  (profile  view)    . 

82.  Scissors  for  removing  sutures  . 

83.  Complete  laceration  of  perinajum 

84.  do.        operation ;  denudation  complete 

85.  do.  "  rectal  sutures 

86.  do.  "  the  remaining  sutures  placed 

87.  Hajmorrhoid  clamp       .... 

88.  Hard-rubber  rectal  tube 

89.  The  operatic m  for  fistula  in  ano 

90.  Mold  of  uterine  cavity  in  the  virgin  (Guyon)  . 

91.  "  "  "  "     multipara  (Guyon) 


vagina) 


Plate  I 

Plate  I 

Plate  11 

Plate  U 

151 

153 

166 

171 

171 

INDEX   TO   ILLUSTRATIONS. 


XI 


Plate  III 


Plate  III 
Plate  III 


FIG. 

92.  Section  of  mucous  membrane  of  uterus 

93.  "       through  corpus  uteri  of  an  infant 

94.  "  "  "  "    of  a  woman  aged  eighty-three 

95.  One  of  the  median  columns  in  the  cervical  canal  (Courty) 

96.  Section  through  the  mucous  membrane  of  cervix  shov/ing  cystic  degen- 

eration     ... 

97.  Elongation  of  the  cervix  (Winckel)   . 

98.  Hypertrophy  of  body  of  uterus  (Winckel) 

99.  General  enlargement  of  uterus  (Winckel) 

100.  Skene's  instillation  tube 

101.  Curette  .... 
103.  Dysmenorrhoeal  membrane  (Simpson) 

103.  Membrane  of  membranous  dysmenorrhoea  (Barnes) 

104.  The  decidual  membrane  expelled  in  abortion 

105.  Bilateral  laceration ;  unequal  division  of  the  cervix 

106.  Bilateral  laceration,  with  thickening  of  the  everted  lips 

107.  Extensive  multiple  laceration 

108.  Multiple  incomplete  laceration 

109.  Incomplete  bilateral  laceration 

110.  "  "  "         in  section 

111.  Crescentie  laceration 
113.  Skene's  hawk-bill  scissors 

113.  Denudation  of  cervix  . 

114.  Skene's  triangular  needles 

115.  Counter-pressure  instrument . 

116.  Sutures  in  place 

117.  Sutures  tied      .... 

118.  Removal  of  crescentie-shaped  piece  (seen  in  section) 
119-120.  Method  of  bringing  the  sides  of  the  section  together 
121-122.  Another  method  of  closing  the  gap 

123.  Partial  inversion  (Thomas) 

124.  Complete  inversion  (Thomas) . 

125.  Polypus  simulating  partial  inversion  (Thomas) 

126.  Polypus  simulating  complete  inversion  (Thomas) 
137.  Byrne's  method  of  reduction  of  inversion 

128.  Cup  pessary  to  exercise  gradual  pressure  (Thomas) 

129.  Replacement  of  uterus  by  dilatation  through  abdomen  (Thomas)  . 

130.  Section  of  pelvis,  showing  its  inclination  and  the  axis  of  the  inlet 

131.  The  normal  range  of  the  uterine  axis  (Van  der  Warker)     . 

132.  Diagi'ara  of  the  uterine  ligaments      ...... 

133.  Section  of  pelvis,  with  the  slings  of  the  uterus        .  .  .  . 

134.  Diagram  of  the  uterus  slung  between  the  broad  ligaments 

135.  The  normal  inclination  of  the  pelvis  and  the  transmission  of  force  from 

above  ..... 

136.  The  three  degrees  of  prolapsus 

137.  Prolapsus  uteri  with  cystocele 

138.  The  shallow  pelvis  with  lessened  inclination  of  brim 

139.  Increased  inclination  of  inlet 

140.  Uterus  replaced,  with  pessary  in  position 

141.  Stem  pessary,  modification  of  Cutter's 

142.  The  three  degrees  of  retroversion 

143.  Retroversion  of  the  second  degree 


PAGE 

172 
173 
174 
175 

181 
182 
182 
182 
189 
198 
232 
232 
233 
244 
244 
245 
245 
346 
246 
247 
250 

250 

251 


354 
254 
254 
266 
266 
269 
269 
276 
276 
378 
280 
281 
282 
384 
384 

285 
287 
291 
292 
293 
298 
300 
305 
306 


xu 


INDEX   TO    ILLUSTRATIONS. 


FIO. 

144.  Retroversion  witli  iuii)i'rfeot  invagination  of  cervix 

145.  Apparent  imperfect  invagination       .  . 

146.  Tlie  same  uterus  witii  its  lips  drawn  back  into  place 

147.  The  three  steps  in  replacing  the  retroverted  uterus  by  means  of 

holders  ...... 

148.  Albert  Smith  pessary  ..... 

149.  Method  of  measuring  tlie  lengtli  of  the  pessary 

150.  Diagram  of  pessary  in  situ  on  looking  througli  Sims's  speculum 

151.  Slight  invagination  of  cervix  posteriorly  with  suital)]e  pessary 
153.  Decided  invagination  of  cervix  posteriorly  fitted  with  a  suitable 

153.  What  the  pessary  does  not  do  .  .  . 

154.  How  the  pessary  acts  ..... 

155.  Second  step ;  the  uterus  falls  into  the  pessary 

156.  The  knee-chest  position  .... 

157.  Fibroid  on  posterior  wall  of  uterus  simulating  retroflexioi 

158.  Trolapsed  and  adherent  ovary  simulating  retrovei'sion 

159.  Extreme  retroflexion  (Barnes) 

160.  Uterus  with  defective  walls ;  the  supra- vaginal  portion  of 

elongated  (after  Winckel)    .... 

161.  Stem  of  pessary  ulcerating  through  cervix    . 
163.  Stem  cutting  through  body  of  uterus 

163.  High  rectocele  due  to  improper  pessary 

164.  Displacement  caused  by  a  badly  adjusted  pessary    . 

165.  Hypertrophy  of  the  cervix      .... 

166.  The  first  step ;  splitting  the  cervix    . 

167.  The  double  flaps  of  the  amputation  . 

168.  Diagram  of  the  pieces  removed 

169.  The  sutures  in  place    ..... 

170.  The  sutures  tied  ..... 
171-173.  Interstitial  fibromata  (Winckel)  . 

173.  Subperitoneal  and  submucous  fibromata  (Winckel) . 

174.  Pedunculated  submucous  fibroid  (Simpson) . 
175-176.  Enlargement  due  to  subinvolution  compared  with  that  from 

of  a  fibroma  (after  "Winckel) 

177.  Ecraseur  ...... 

178.  Wall  of  uterus  caught  in  ecraseur-wire  and  removed 

179.  Electrical  action  in  a  single  cell 

180.  Law  cell  ...... 

181.  Milliamperemeter         ..... 
183.  Rheostat  ...... 

183.  Uterine  electrode         ..... 

184.  Cancer  of  both  lips  (Winckel) 

185.  The  fundus  uteri  and  ovaries  seen  through  the  pelvic  brim 

186.  The  ovary  and  its  ligaments  (Henle) . 

187.  The  ovarian,  uterine,  and  vaginal  arteries  (Hyrtl)    . 

188.  Section  of  the  ovai-y  of  a  bitch  (Waldeyer)   . 

189.  Ovary  displaced  and  bound  down  by  adhesions 

190.  Left  ovary,  one  large  cyst  (Farre) 

191.  Compoimd  and  proliferating  cyst  (Farre) 
193.  Multiloeular  cyst  (Hooper)      .... 

193.  Papillary  cystoma  of  ovary  (Winckel) 

194.  Dermoid  cyst  of  ovary  (Winckel) 


sponge- 


pessary 


the  cervix  is 


(His) 


growth 


INDEX   TO   ILLUSTRATIONS. 


xui 


FIG.  PAGE 

195.  Fibroma  affecting  both  ovaries  (Winckel)     .....  478 

196-197.  Area  of  dullness  in  ovarian  tumor  and  in  ascites  (Barnes)       .            .  495 

198.  Cautery  clamp  .........  513 

199.  Keith's  short  compression-forceps      ......  519 

200.  Keith's  long  compression-forceps       ......  519 

201.  Keith's  needle  .........  520 

202.  Keith's  ligature-forceps           .......  520 

203.  Baker- Brown  clamp     ........  520 

204.  Position  of  operator,  assistants,  and  accessories  in  ovariotomy       .'           .  521 

205.  Diagrammatic  transverse  section  of  the  pelvis  (Lusehka)    .            .            .  555 

206.  Pelvic  abscess  opening  obliquely  downward  .            .            .            .            .  557 

207.  Pelvic  abscess  opening  obliquely  upward      .....  557 

208.  The  pelvic  peritonfeum  (Hodge)         ......  579 

209.  The  reflections  and  pouches  of  the  pelvic  peritonaeum  (Hodge)      .            .  580 

210.  Retroverted  uterus  bound  back  by  peritonitic  adhesions  (Winckel)           .  582 

211.  Subperitoneal  pelvic  hematocele        ......  596 

212.  Intra-peritoneal  pelvic  hEBmatocele    ......  597 

213.  Diagram  of  the  bladder  to  show  corpus  and  fundus             .            .            .  610 

214.  Base  and  neck  of  the  bladder  (Savage)          .....  612 

215.  Urethra  laid  open  with  probes  distending  the  glands  (posterior  wall  di- 

vided)            .........  614 

216.  Urethra  laid  open  with  probes  in  Skene's  glands  (anterior  wall  divided)  .  614 

217.  Transverse  section  of  urethra  with  gland  on  either  side      .             .             .  615 

218.  Longitudinal  section  of  urethral  glands        .....  616 

219.  The  meatus  everted  showing  the  mouths  of  the  glands       .            .            .  617 

220.  The  relations  of  the  ureters  (Garrigues)        .....  620 

221.  Extroversion  of  the  bladder    .  .  .  ,  .  .  . .  638 

222.  Linear  cicatrix             ........  639 

223.  Bladder  covered  by  deep  flaps            ......  640 

224.  Diagram  of  the  result  of  the  operation          .....  641 

225-227.  Skene's  endoscope  .  .  .  .  .  ,  .695 

227a.  Principal  of  the  Nitze-Leiter  cystoscope    .....  697 

227&.          "             "                «                  ".....  698 

227c.  Leiter  cystoscope        ........  698 

328.  Skene's  bivalve  urethral  speculum     ......  700 

229.  Fountain-syringe  for  washing  bladder          .....  740 

230.  Skene's  instillation-tube  .  .  .  .  .  .  .743 

231.  Skene's  urinal  cup-pessary      .......  747 

232.  Holt's  catheter,  with  its  modifications           .....  749 

233.  Skene's  modifieatiou  of  Goodman  self-retaining  catheter    .            .            .  749 

234.  Retroversion  of  the  gravid  uterus  (Schatz)   .....  762 

235.  Skene's  pessary  for  prolapsus  of  the  bladder             ....  767 

236.  Pessary  holding  up  the  bladder  .  .  .  .  .  .768 

237.  Modification  of  the  retroversion  pessary,  used  in  prolapsus  of  the  bladder  768 

238.  Forward  transposition  of  the  uterus  ......  773 

239.  Retrocession  of  the  uterus      .......  774 

240.  Skene's  reflux  catheter  .  .  .  .  .  .  .822 

241.  Skene's  fissure  probe  and  knife           ......  833 

242.  Skene's  urethral  speculum      .......  844 

243.  Skene's  modification  of  Folsom's  nasal  speculum     ....  844 

244.  Allen's  polypus  forceps           .......  845 

245.  Blake's  polypus  snare  ........  846 


XIV 


INDEX   TO   ILLUiSTKATlONS. 


FIO. 

24(5.  Dilatation  of  middle  third  of  the  urethra 

247.  Skene's  button-liole  scissors    . 

248.  Dislocation  of  upper  third  of  urethra 

249.  Complete  dislocation  with  dilatation 
249a.  Operation  for  prolapse  and  dilatation 
249b.  Growths  at  the  mouths  of  the  glands 

250.  Siras's  tenaculum 

251.  Operation  for  vesico-vaginal  fistula;  paring  the  edges 

252.  Sims's  sponge-holder  .... 

253.  Emmet's  needles  ..... 

254.  Curved  track  of  the  needle     .... 

255.  Operation  for  vesico-vaginal  fistula ;  the  sutures  in  place 

256.  Two  sutures  tied  ..... 


PAGE 

852 
8G0 
801 
802 


Plate  IV 
Plate  IV 


897 
898 
898 
899 
899 
900 
900 


Plate  I,  Fig.    83.  Complete  laceration  of  perinieum. 
I,  Fig.    84.  do.       operation ;  denudation. 

n,  Fig.    85.  do.  "  rectal  sutures. 

II,  Fig.    86.  do.  "  remaining  sutures. 

Ill,  Fig.  113.  Bilateral  laceration  of  cervix;  denudation. 
Ill,  Fig.  116.  do.      sutures  in  place, 

III,  Fig.  117.  do.       sutures  tied. 

IV,  Fig.  249«.  Prolapse  of  urethra;  operation. 

IV,  Fig.  2496.  Growths  at  mouths  of  Skene's  glands. 


Note. — All  illustrations  not  credited  are  from  original  di'awings  by  Robert  L. 
Dickinson,  M.  D.,  excepting  instruments,  and  Figs.  92,  93,  94,  96,  217,  and  218,  by 
J.  M.  Van  Cott,  jr.,  M.  D.,  and  Figs.  215  and  216,  by  A.  H.  P.  Leuf,  M.  D. 


DISEASES  OF  WOMEN. 


CHAPTER  I. 

METHODS    OF    OBSERVATION. 

A  THOROUGH  familiarity  witli  the  means  and  methods  of  investi- 
gation is  the  first  requisite  in  acquiring  knowledge.  The  art  of  ob- 
servation, which  is  simply  the  systematic  use  of  the  mental  and  phys- 
ical faculties  to  obtain  facts,  should  be  made  an  essential  part  of  the 
preliminary  ti'aining  of  every  student  of  medicine.  From  this  point 
of  view,  the  subject  which  we  have  to  consider  resolves  itself  into 
two  divisions:  first,  the  ways  and  means  of  investigation;  and,  sec- 
ond, the  objects  to  be  studied. 

Before  approaching  the  study  of  gynecology,  it  is  taken  for 
granted  that  much  experience  and  practice  have  been  attained  by 
the  student  in  the  art  of  investigation.  The  experience  of  every- 
day life,  from  infancy  onward,  and  the  ordinary  school  education 
obtained  before  beginning  the  study  of  medicine,  tend  to  develop 
and  cultivate  the  perceptive  faculties.  Still,  the  physician  and  sur- 
geon require  special  training  in  the  art  of  observation.  Accurately 
noting  stracture,  form,  color,  general  proportions,  and  expressions  of 
the  human  body  in  health,  is  the  first  lesson  which  every  student  of 
medicine  should  learn.  This  is  the  most  important  step  towai'd  the 
attainment  of  a  practical  knowledge  regarding  the  functions  of  the 
human  body,  and  its  deformities,  diseases,  and  injuries.  The  cor- 
rect, rapid,  and  thorough  observer  has  from  the  outset  great  advan- 
tages. Important  and  necessary  as  this  branch  of  education  is,  it  is 
almost  wholly  neglected  in  schools  and  colleges.  The  chief  occupa- 
tion of  teachers  appears  to  be  to  impart  knowledge  already  in  exist- 
ence, rather  than  to  qualify  the  student  to  observe  and  think  for 
himself. 

Special  attention  should  be  given  to  this  art  of  observation,  be- 
cause it  is  the  key  to  science  and  the  first  exercise  in  practice.  The 
2 


2  DISEASES   OF   WUMEN. 

systematic  way  in  which  kiunvledge  is  presented  in  books  and  by 
oral  instruction  enables  the  student  to  acquire  facts  in  all  brandies  of 
learning,  and  to  classify  them.  The  mental  training  ol)tained  in  the 
study  of  mathematics  and  logic  prepares  men  to  make  reasonable 
deductions  from  the  facts  obtained  ;  but  in  institutions  of  learning, 
thorour>:h  trainino;  in  the  art  of  observation  is  seldom  given. 

This  lack  of  preliminary  education  adds  greatly  to  the  labors  of 
the  student,  because  he  is  obliged  to  acquire  knowledge  while  he  is 
not  in  possession  of  the  means  of  obtaining  it,  and  it  is  mainly  be- 
cause of  this  defect  that  practitioners  of  medicine  are  led  into  error 
in  making  diagnoses.  They  fail  to  observe  all  the  facts,  and  hence 
their  deductions  are  liable  to  be  incorrect. 

Acute,  clear  perception  is  a  gift  which  all  do  not  possess  in  a 
high  degree,  but  it  can  be  cultivated  in  those  of  ordinary  intelli- 
gence, and  it  should  be  by  those  who  intend  to  practice  medicine. 
The  practical  study  of  the  elements  of  natural  science,  which  should 
constitute  a  large  share  of  the  early  education  of  tliose  destined  for 
the  profession  of  medicine,  aids  much  in  cultivating  the  faculties 
concerned  in  obsei*vation.  So  also  the  arts,  especially  drawing, 
painting,  and  sculpture,  help  to  qualify  for  the  actual  in  professional 
life.  The  trained  eye  and  hand  of  the  artist  are  most  valuable  in 
acquiring  the  art  of  medicine  and  surgery,  and  a  share  of  the  days 
of  youth  spent  at  an  art-scliool  will  save  much  time  and  perplexity 
in  the  medical  school  as  well  as  in  subsequent  professional  life. 

The  tirst  lesson  is  to  obtain  a  familiarity  with  the  general  appear- 
ance of  the  body  in  health,  its  structure  and  the  uses  of  the  various 
organs,  the  process  of  development,  the  slight  deviations  from  the 
ideal  or  highest  type  which  occur  within  the  range  of  health,  and 
finally  the  relations  of  the  being  to  his  enviromnents  or  conditions 
of  life.  A  portion  of  this  subject  will  be  fully  discussed  in  the 
chapter  on  the  development  and  structure  of  the  se.xual  organs  of 
woman,  and  the  conditions  of  life  which  are  suitable  to  her  develop- 
ment, gro^vth,  and  maintenance.  Subsequently  the  derangements 
of  the  body  from  disease  and  injury  will  come  in  for  the  greater 
portion  of  time  and  attention.  Here  it  is  that  the  highest  per- 
ceptive power  is  needed,  and  the  most  jiainstaking  attention  to  ob- 
servation. 

The  fact  should  be  kept  clearly  in  mind  that  a  knowledge  of  the 
science  of  medicine  does  not  give  skill  in  the  art  of  practice,  how- 
ever much  it  may  help  in  accjuiring  that  art.  Men  profoundly 
versed  in  the  science  of  medicine  may  be  poor  practitioners ;  and 
others,  whose  knowledge  of  the  science  is  very  limited,  may  attain 


METHODS  OF   OBSERVATION.  3 

some  reputation  in  ])ractice ;  but  the  Lest  qualified  physician  is  he 
who  knows  most  of  both  the  science  and  the  art. 

The  subject  for  present  consideration  is  the  method  of  investi- 
gation to  be  adopted  in  practicing  the  art  of  gynecology.  Before 
beginning  the  actual  work  of  examining  patients,  it  is  necessary  to 
know  how  to  do  so. 

There  are  several  methods  of  investigating  the  sick  and  injured 
given  in  text-books  and  taught  in  the  medical  schools,  but  most  of 
these  are  better  adapted  to  general  practice  than  to  special  depart- 
ments of  medicine.  The  methods  which  I  desire  to  present  here  are 
circumscribed,  and  perhaps  less  complicated,  because  they  are  limited 
to  the  diseases  peculiar  to  women. 

In  examining  patients  it  is  well  to  first  settle  definitely  in  the 
mind  the  object  to  be  attained  and  how  to  attain  it.  Some  rational 
system  of  investigation  should  be  mastered  in  all  its  details  before 
undertaking  actual  practice.  To  engage  in  clinical  study  ^vithout 
such  preparation  is  like  trying  to  read  a  language  without  knowing 
its  alphabet. 

The  system  advised  is — first,  obtain  all  the  facts  regarding  the 
case  in  hand ;  second,  arrange  the  facts  in  their  natural  relation  to 
one  another ;  and,  finally,  make  deductions  from  the  data  thus  ob- 
tained. These  will  be  easily  remembered  in  the  following  order 
and  association:  observation,  classification  of  things  observed,  and 
conditions  indicated  by  the  sum  of  the  information  obtained. 

The  examination  of  a  patient  should  begin  by  a  general  inspec- 
tion ;  and,  in  order  to  make  that  inquiry  complete  and  profitable, 
certain  questions  should  be  raised  in  the  mind  of  the  examiner; 
such,  for  example,  as  what  is  the  general  appearance  of  the  patient 
under  observation  ?  What  size  ?  Regular  or  defective  in  general 
outline?  Lean  or  corpulent?  What  temperament?  Is  the  face 
pale  or  flushed?  Languid  or  vigorous?  Sad  or  cheerful?  Calm 
or  excited  ?  Intelligent  or  stupid  ?  What  diathesis  is  indicated,  if 
any?  In  short,  does  the  genei'al  physigonomy  indicate  health  or 
disease  ? 

All  these  interrogations  are  made  by  lookiug  critically  at  the 
patient.  There  are  so  many  questions  to  be  answered  in  this  con- 
nection, that  one  may  find  some  difficulty  in  promptly  remembering 
them ;  but  by  patient  practice  the  mind  and  eye  can  be  trained  to 
take  advantage  of  a  rule  of  obseiwation  employed  by  critical  investi- 
gators in  other  arts,  which  is  this :  having  a  type  of  noraial  organi- 
zation in  mind,  the  observer  is  able  to  scan  a  given  case,  and  detect 
any  deviation  from  that  standard  of  liealthy  formation  and  appear- 


4  DISEASES   OF   WOMEN. 

ance.  Tlie  artist,  in  looking  at  a  picture  or  statue,  does  not  neces- 
sarily question  every  line  of  the  drawing  or  form  by  itself,  but 
his  trained  eye  catches  any  defects  that  there  may  be  in  the  work 
before  him. 

The  classification  of  facts  is  simply  putting  together  those  which 
are  similar  in  character.  The  arrangement  of  material  things  in 
groups  is  familiar  to  all.  A  well-arranged  library,  in  which  all 
books  pertaining  to  a  given  subject  are  placed  side  by  side,  is  a  fair 
illustration  of  this  kind  of  classification.  Facts  and  ideas  can  be 
arranged  in  the  mind  upon  precisely  the  same  principle.  The  ad- 
vantage of  classification  is  that  it  aids  comprehension  and  memory. 
By  recalling  one  group  of  facts  which  have  been  associated  in  the 
mind,  the  rest  will  follow  in  easy  and  natural  order.  There  are  two 
methods  of  classifying  the  information  contained  in  the  clinical  his- 
tory of  a  patient.  One  is  to  obtain  all  the  facts  possible,  and  then  to 
arrange  them  in  order.  The  other  is  to  classify  them  at  each  step 
of  the  examination.  The  former  method  requires  a  mental  grasp 
and  tenacity  which  few  possess,  and  therefore  I  would  advise  the 
latter. 

The  information  obtained  by  inspection  may  be  classed  under 
four  heads :  1.  The  original  character  of  the  organization,  whether 
perfect  or  imperfect  in  structure  and  function.  2.  If  im])erfect, 
whether  from  imperfect  development,  causing  lesions  of  form  or 
lesions  of  structure,  or  from  inherited  or  acquired  disease,  and  inher- 
ited tendencies  to  disease,  known  as  diathesis.  3.  Evidences  of  dis- 
ease, expressed  in  the  face,  either  acute  or  chronic.  4.  The  tem- 
perament ;  which  simply  means  the  preponderance  of  a  certain 
portion  or  poi'tions  of  the  organization. 

To  illustrate  the  value  of  this  process  of  general  inspection  of 
patients,  the  partial  history  of  a  case  seen  in  private  practice  will 
suffice.  A  lady  called  to  consult  me  regarding  her  son,  a  little  fel- 
low seven  years  of  age.  After  a  very  brief  survey  of  the  patient,  I 
saw  enough  to  satisfy  me  that  he  had  recently  had  scarlatina,  and 
that  when  a  child  he  had  suffered  from  sore  eyes,  and  that  his  father 
had  been  subject  to  rheumatic  pains  in  years  gone  by.  The  mother 
acknowledged  that  T  was  right  in  every  ]iai'ticular.  A  glance  at  the 
boy  showed  that  exfoliation  of  the  cuticle,  which  occui-s  after  scar- 
latina, Avas  still  going  on ;  the  face  was  pale  and  puffy,  indicating 
commencing  dropsy  from  acute  nephritis,  a  sequel  of  the  eruptive 
fever.  I  also  noticed  that  he  had  a  scar  upon  the  cornea  of  each 
eye,  the  result  of  a  former  keratitis.  The  form  of  his  nose  and  the 
character  of  his  teeth  indicated  an  inherited  syphilis ;  and  from  the 


METHODS   OF  OBSERVATION.  5 

appearance  of  his  mother  and  other  facts  known  to  me,  I  presumed 
that  the  father  was  the  one  who  had  transmitted  the  specific  disease. 

The  age  of  the  patient  should  be  ascertained,  because  that  sug- 
gests the  possible  existence  of  the  diseases  which  are  likely  to  occur 
at  certain  periods  of  life.  Care  should  be  taken  to  compare  the  real 
and  apparent  age,  in  order  to  ascertain  if  the  patient  is  prematurely 
old,  or  well  jjreserved.  This  interrogation  will  also  serve  to  keep  in 
mind  the  fact  that,  in  early  life,  acute  diseases  prevail,  while  degen- 
erations are  usually  limited  to  advanced  life. 

It  is  important  to  know  the  social  relations  of  a  patient — that  is, 
whether  she  is  married  or  single.  If  married,  she  is  liable  to  the 
diseases  and  accidents  attendant  upon  child-bearing.  If  she  has 
never  been  pregnant,  her  sterility  may  have  resulted  either  from 
choice,  or  because  of  some  defect  in  her  organization.  Women  who 
are  single  are,  by  reason  of  that  fact,  limited  in  the  range  of  diseases 
of  their  sexual  organs,  and  this  may  be  taken  for  granted  unless  evi- 
dence to  the  contrary  is  obtained. 

Having  made  a  general  inspection  of  a  given  case,  and  ascer- 
tained the  age  and  social  relations,  an  examination  of  the  various 
portions  of  the  body  should  next  be  made  in  systematic  order.  To 
do  this  conveniently,  one  group  of  organs  or  one  system  should  be 
examined  at  a  time.     The  various  systems  are  classified  as  follows : 


THE   NERVOUS,    NUTRITIVE,  MUSCULAR,   AND   SEXUAL 

SYSTEMS. 

The  first  three  are  subdivided  as  follows  :  The  nervous  has  two 
grand  divisions,  the  cerebro-spinal  and  organic.  The  nutritive  has 
four  subdivisions,  the  digestive,  circulatory,  lymphatic,  and  excre- 
tory ;  and  the  third  has  the  osseous  and  muscular. 

The  present  purpose  is  to  outline  the  methods  of  investigating 
the  sexual  system,  but,  in  order  to  do  that  successfully,  it  is  necessary 
to  be  able  to  examine  the  whole  body.  Xo  one  can  be  a  trustworthy 
specialist  without  having  a  thorough  knowledge  of  the  whole  organi- 
zation. All  the  parts  of  the  body  are  so  bound  together  by  mutual 
relations  that  one  can  not  accurately  diagnosticate  the  diseases  of 
one  portion  without  knowing  the  condition  of  all  the  others.  On 
account  of  that  fact  I  must  refer  to  the  principles  upon  which  the 
examination  is  made  of  parts  other  than  the  sexual  system. 

Briefiy,  it  may  be  stated  that  the  two  principal  subjects  of  in- 
quiry are  the  condition  of  the  function  and  stiiicture  of  the  organs 
under  examination.     Perverted  function  of  the  cerebro-spinal  divis- 


6  DISEASES  OF  AVOMEN. 

ion  of  the  nervous  system  is  nianifested  through  derangemeuts  of 
sensation  aud  motion,  and  abnormal  states  of  tlie  organic  nerves  is 
indicated  where  nutrition  is  deranged,  wliile  the  organs  of  nutrition 
are  free  from  organic  disease.  The  condition  of  the  circulatory 
system  is  indicated  by  the  color  of  the  skin  and  mucous  membranes, 
the  chai'acter  of  the  j)ulse,  and  the  heart-sounds. 

The  general  nutrition  nuiy  be  estimated  by  the  appetite  for  foot), 
the  excretions,  and  the  state  of  the  tissues  generally.  These  are 
meager  hints,  but,  if  kept  iii  mind  while  examining  cases  in  the  de- 
partment of  gynecology,  will  guard  against  the  mistake  of  overhjok- 
ing  affections  of  the  general  sj'stem,  which  might  modify  or  cause 
diseases  of  the  sexual  system. 

In  applying  the  principles  already  hinted  at  in  the  investigations 
of  special  diseases  of  the  sexual  organs,  we  lind  that  morbid  action  is 
manifested  by  symptoms  aud  i)hysical  signs.  The  symptoms  may 
])e  classed  under  three  heads  :  First,  deranged  nei"ve-action ;  sec- 
ond, deranged  functions  of  the  organs  affected ;  and,  third,  modified 
locomotion. 

First  Class  (nerve-symptoms). — Pelvic  pains  not  specially  local- 
ized ;  sacral  pain ;  pain  of  certain  pelvic  organs ;  pains  beginning 
in  the  [)elvis  and  radiating  to  other  parts  of  the  body. 

Second  Class. — Derangements  of  function,  such  as  deranged  men- 
struation ;  sterility ;  abnormal  discharges ;  deranged  function  of  the 
bladder  and  rectum. 

Third  Class. — Aggravation  of  any  or  all  of  the  above-named 
symptoms,  by  standing,  walking,  or  other  muscular  exercise. 

Keeping  this  classification  in  mind,  (questions  will  suggest  them- 
selves, the  answers  to  which  will  determine  the  presence  or  absence 
of  these  symptoms.  One  should  know  the  symptoms  which  belong 
to  a  given  disease,  and  then  ascertain  if  they  are  present  by  asking 
questions  of  the  patient.  Cori-ect  testimony  will  more  surely  be  ob- 
tained in  this  way  than  by  depending  upon  the  voluntary  statements 
of  the  person  examined. 

Tlie  following  plan  will  be  of  service  in  obtaining  the  symp- 
toms referred  to  in  the  three  classes  given  above  :  First,  ask  if  the 
patient  has  pain  and  where  it  is  located.  Ascertain  also  if  this  pain 
is  connected  with  any  of  the  functions  of  the  pelvic  organs.  Then 
obtain  the  history  of  the  functions  of  the  sexual  organs,  in  the 
past  and  j^resent.  These  facts  can  be  obtained  from  the  patient 
herself,  aided  perhaps  by  some  one  who  knows  her  well.  Some 
l)ractice  is  necessary  to  acquire  skill  in  taking  testimony,  the  value 
of  which  depends  largely  upon  the  physician's  ability  to  make  the 


METHODS   OF   OBSERVATION.  f 

patient  answer  his  questions  correctly.  Such  questions  as  tlie  fol- 
lowing regarding  tlie  menstrual  function  should  be  asked :  At  what 
age  was  tlie  menstrual  function  Urst  established  i  At  what  periods 
of  time  has  it  recurred  ?  How  long  does  it  continue  each  time  ? 
What  are  the  quantity  and  character  of  the  flow  ?  Is  it  attended  with 
pain,  and  if  so,  where  is  the  pain  located,  and  at  what  time  does  it 
occur  in  relation  to  the  menstrual  flow  ?  Has  menstruation  always 
been  attended  with  pain,  or  only  for  a  limited  period  in  the  history 
of  that  function  ?  And,  Anally,  is  menstruation  attended  with  de- 
rangements of  any  of  the  other  functions  of  the  body  ? 

From  the  answers  to  these  questions  two  points  can  be  decided : 
First,  whether  menstruation  has  been  performed  normally  during 
the  whole  or  part  of  the  patient's  menstrual  period  of  life  ;  and,  sec- 
ond, if  any  derangement  of  that  function  exists,  whether  it  be  in 
character,  recurrence,  duration,  or  quantity. 

Next  in  order  comes  the  history  of  reproduction.  Has  the  pa- 
tient had  children,  and  if  so,  how  many,  and  when  i  Has  she  mis- 
carried ?  K  she  has,  at  what  period  of  gestation,  and  at  what  time 
in  relation  to  birth  of  living  children  if  she  has  had  any  i  Was 
there  anything  abnormal  in  her  pregnancies,  confinement,  or  recov- 
ery from  labor  ;  if  so,  what  ?  The  answers  to  these  questions  will 
determine  whether  the  present  conditions  date  back  to  some  of  the 
diseases  or  accidents  of  pregnancy  or  parturition.  H  the  history  so 
far  obtained  indicates  any  disease  or  functional  derangement  of  the 
sexual  organs,  and  there  is  any  accompanying  affection  of  the  general 
system,  the  question  arises,  regarding  the  relations  which  they  sus- 
tain to  one  another.  That  question  can  frequently  be  settled  by 
ascertaining  which  of  the  two  affections,  the  local  or  general,  ap- 
peared first.  The  one  which  precedes  is  frequently  the  cause  of 
that  which  follows. 

Thus  far  we  have  been  dealing  with  symptoms  which,  as  a  rule, 
reveal  only  derangements  of  function.  They  are  but  expressions 
of  disease,  and  do  not  in  all  cases  indicate  the  conditions  of  the 
organization  which  cause  the  derangement  of  function. 

This  brings  us  to  the  final  division  of  our  subject,  viz.,  the  phys- 
ical signs  of  disease.  These  are  the  physical  evidences  of  change 
of  structure.  There  are  exceptions  to  the  general  rule  that  these 
physical  evidences  are  always  present,  but  they  ai'e  few  in  number, 
and  therefore  may  be  omitted  in  our  general  consideration  of  the 
subject. 

The  changes  of  structure  and  organization  in  the  sexual  organs, 
which  are  expressed  by  physical  signs,  are  as  follows ; 


8 


DISEASES   OF  AVOJrfEN. 


Changes  of  position,  form,  size,  consistence,  composition,  color 
or  appearance,  and  degree  of  sensitiveness. 

The  means  of  obtaining  })hysical  signs  are  tlie  touch  —  single 
or  bimanual — jxUpation,  percussion,  speculum,  sound,  probe,  curette, 
exploring-needle,  uterine  dilator,  and  microscope. 

The  art  of  employing  these  means  next  claims  attention. 


EXAMINATION    BY    THE    TOUCH. 

This  examination  is  most  conveniently  practiced  when  the  pa- 
tient is  ])laced  upon  a  suitable  table.  One  that  is  thirty-three 
inches  higli.  forty-three  inches  long,  and  twenty -three  inches  wide, 
having  a  projection  on  the  right-hand  coraer  upon  which  to  rest 
the  feet,  answers  better  than  anv  table  or  chair  that  I  have  ever  seen. 


Fk;.  1. — Examining  table.     (The  upper  part  of  the  foot-rest  folds  down  as  the  dotted  lines 
show,  and  the  support  can  be  pushed  in.) 

The  patient  should  be  placed  upon  the  back,  with  the  pelvis  as 
near  the  end  of  the  table  as  possible,  permitting  the  heels  to  rest 
upon  the  table  also,  while  the  thiglis  are  iiexed  upon  the  body  and 
the  legs  upon  the  thighs.  A  sheet  held  by  the  edge  in  both  hands 
is  drawn  over  the  limbs  from  the  feet  upward,  at  the  same  time 
that  the  skirts  are  pushed  up  ont  of  the  way.  This  protects  the 
patient  from  exposure. 

In  this  examination  the  index-fincrer  of  the  rio-ht  hand  is  gener- 
ally  employed,  but  both  right  and  left  should  be  educated,  because 
it  is  sometimes  difficult  to  examine  that  side  of  the  pelvis  which 
faces  the  back  of  the  hand  used.     In  critical  cases,  therefore,  it  may 


METHODS   OF   OBSERVATION. 


be  necessary  to  employ  both  Lands,  first  one  and  then  the  other,  in 
order  to  complete  the  examination.  In  the  majority  of  cases  it  is 
requisite    to    employ 


the  bimanual  metliod, 
as  it  is  termed — that 
is 
introduced 


,  while  one  finger  is 


into  the 
vagina,  the  fingers  of 
the  other  hand  are 
placed  upon  the  abdo- 
men at  the  pelvic  in- 
let, and  by  pressure 
the  parts  are  brought 
down  to  within  near 
reach  of  the  finger  in 
the  vagina.  Fig.  2 
illustrates  the  mode 
of  making  this  exam- 


FiG.  2. — Bimanual  examination. 


ination.  This  method 
is  quite  satisfactory  in  spare  patients  with  lax  abdominal  muscles ; 
but  when  the  muscles  are  tense,  and  when  the  walls  of  the  abdomen 
contain  a  thick  layer  of  adipose  tissue,  the  examiner  will  find  great 
difficulty  in  practicing  it.  In  sneh  unfavorable  conditions,  when  the 
diagnosis  is  obscure,  much  will  be  gained  by  using  an  anaesthetic. 

Examination  of  the  pelvic  organs  through  the  rectum  is  of  great 
value.  In  this  method  the  touch  is  practiced  in  the  same  way  as  in 
that  already  described. 

There  are  other  methods  practiced,  such  as  introducing  two  fin- 
gers into  the  vagina,  the  index  and  the  middle  ;  and  the  introduction 
of  the  whole  hand  into  the  vagina  or  into  the  rectum.     Simon's 

o 

method  is  to  first  dilate  the  sphincter-ani  muscle,  and  then  pass  the 
whole  hand  into  the  rectum  as  far  up  as  need  be.  Extraordinary 
advantages  have  been  claimed  for  this  method,  which  brings  all  the 
pelvic  organs  within  the  grasp  of  the  examiner ;  but  it  has  proved  to 
be  dangerous,  and,  owing  to  the  fact  that  pressure  benumbs  the  hand, 
it  is  more  difficult  than  it  appears  to  be  theoretically.  It  should 
not  be  practiced,  except  in  rare  cases  in  which  it  is  of  vital  impor- 
tance to  make  an  accurate  diagnosis  that  can  not  otherwise  be  made. 
These  methods  are  not  without  danger,  and  always  do  less  or  more 
violence  to  the  parts,  and  are  only  practiced  in  rare  and  obscure 
cases,  mostly  those  of  tumors.  Dilatation  of  the  urethra  sufficient  to 
admit  the  finger  has  been  practice  1  and  advised  for  the  purpose  of 


10  DISEASES   OF    Wo.MKN. 

aiding  in  the  exploration  of  tlie  pelvic  organs,  but  tlie  information 
gained  in  this  way  does  not  compensate  for  the  suffering  and  danger  ; 
liOTice  tlic  j)ractici"  is  rarely  called  for,  and  still  more  rarely  admissible. 

Digital  Touch  by  the  Eectum. — This  method  is  generally  restarted 
to  when  some  obscure,  abnormal  condition  has  been  discovered  by 
the  vaginal  touch.  Much  satisfactory  information  can  be  obtained 
in  this  way,  especially  regarding  the  posterior  wall  of  the  uterus, 
the  ovaries,  and  the  sac  of  Douglas. 

The  bimanual  method  of  practicing  the  rectal  touch  is  the  same 
as  the  vaginal.  Pressure  upon  the  hypogastrium  with  the  external 
hand  gives  the  ei>njoiiied  aid,  as  in  examining  by  the  vagina. 

Vesico-Vaginal  Examination. — In  this  method  a  sound  is  ])assed 
into  the  bludder  wliile  the  finger  is  in  the  vagina.  By  this  means 
certain  states  of  the  vagina,  urethra,  and  bladder  are  investigated. 

Vesico-Rectal  Examination. — This  is  the  same  as  the  vesico-vagiual 
except  that  the  finger  is  introduced  into  the  rectum.  It  is  the  more 
valuable  of  the  two  in  exploring  all  that  lies  between  the  bladder 
and  rectinn. 

Palpation. — Whenever  the  touch  discovers  anything  abnormal^ 
as  a  tumor,  an  enlargement  of  the  uterus,  or  products  of  inflamma- 
tion, additional  information  can  be  obtained  by  abdominal  palpation. 
This  is  accomplished  by  manipulating  the  abdomen  so  as  to  outline 
the  part  in  question,  and  to  test  its  sensitiveness,  mobility,  and 
density.     Both  hands  are  usually  emjiloyed  in  this  examination. 

Percussion. — It  is  unnecessary  to  describe  the  manner  of  practicing 
percussion.  Suffice  it  to  say  that  percussion  is  practiced  in  exactly 
the  same  way  in  exploring  the  abdomen  as  it  is  in  exploring  the 
thorax,  the  object  being  to  test  the  density  of  the  abnormal  part  and 
outline  its  relations  to  the  alxloniinal  organs. 

Palpation  and  Percussion  Conjoined. — This  consists  in  resting  the 
lingers  of  one  hand  at  one  j)oint  on  the  al)domiual  walls  and  making 
percussion  at  another  point.  Its  chief  object  is  to  ascertain  if  there 
is  fluid  present ;  this  is  shown  by  fluctuation.  There  are  three  ways 
of  accomplishing  this:  The  first  is  to  select  points  on  the  distended 
al)domen  directly  opposite  one  another,  resting  the  fingers  lightly  at 
one  ]mrt,  and  ])ercussing  at  the  other.  This  is  known  as  the  dia- 
metrical method.  The  second,  the  peripheral  method,  is  to  take 
])oints  on  a  section  of  the  al)domen  and  manipulate  in  the  same  way. 
The  third  consists  in  resting  the  fingers  at  one  point  and  making 
pressure  at  the  other,  to  see  if  the  part  is  wholly  movable  or  partially 
so.  This  differs  from  the  others  essentially  in  substituting  inter- 
rupted pressure  for  percussion. 


METHODS   OF   OBSERVATION. 


11 


Fig.  3. — Sims's  speculum 


The  Speculum. — This  instrument  is  twofold  in  its  use.  It  is  one 
of  the  most  important  aids  in  tlie  investigation  of  disease,  and  at 
the  same  time  a 
necessary  instru- 
ment in  treat- 
ment. A  great 
variety  of  spec- 
uhi  are  used, 
but  two  answer 
all  requirements. 
Sims's  speculum 
and  Cusco's  bi- 
valve, slightly 
modified,  answer 

ever}'  indication.  In  fact,  Sims's  speculum  is  all  that  is  needed,  ex- 
cept when  an  assistant  or  nurse  can  not  be  obtained  to  hold  the  specu- 
lum, then  Cusco's 
may  be  employed 
with  advantage  in 
examining  the  cer 
vix  uteri,  and  for  the 
purpose  of  making 
applications  thereto. 
In  using  Sims's 
speculum  it  is  ne- 
cessary to  have  the 
patient  upon  the 
table  already  de- 
scribed, which  should  be  near  a  window  giving  a  good  light.  Oc- 
casionally it  may  be  necessary  to  examine  a  patient  upon  the  bed, 
but  this  is  difficult,  and  should  not  be  undertaken  until  the  ex- 
aminer has  acquired  by  practice  great  facility  in  the  use  of  the 
instrument,  and  only  then,  when  it  is  impracticable  to  place  the  pa- 
tient upon  the  table. 

The  position  of  the  patient  should  be  on  the  left  side,  semi-prone, 
\rith  the  left  arm  behind  the  back,  the  head  upon  a  low  pillow,  and 
near  the  right-hand  side  of  the  table,  the  limbs  di'awn  up,  the  right 
limb  above  and  in  front  of  the  left,  and  the  pelvis  at  tlie  end  of  the 
table  on  the  left-hand  side.     Fig.  5  illustrates  this  position. 

In  order  to  place  the  patient  in  this  position,  she  should  stand  upon 
an  ottoman  or  low  chair,  with  her  left  side  toward  the  end  of  the 
table.     The  skirts  on  the  left  side  are  then  raised,  and  she  is  directed 


Fig.  4. — Cusco's Tiivalve  speculum. 


12 


DISEASES   OF   WOMEN. 


to  sit  down  oii  the   tablu  ;  lier  left   luuid  is  ])hiced  beliind  the  hack, 
and  she  is  made  to  lie  down  on  the  left  side,  inclining  forward.    Tlie 


Fig.  5. — Sims'p  position,  seen  from  above. 


I'k;.  Ci. — Nurse  liolding  Sinis's  spccuiuni. 


limbs  are  at  the  same  time  drawn  up  and  placed  in  pr(>j)er  position. 
The  skirts  are  then  pushed  uj)  on  the  right  side,  and  at  the  same 


METHODS   OF   OBSERVATION. 


ly 


time  a  sheet  is  di'awii  over  the  limbs  and  arranged  so  as  to  expose 
the  labia  only. 

The  speculimi  is  introduced  by  separating  the  la])ia  "with  the 
fingers  of  the  left  hand,  holding  the  instrument  in  the  right  hand 
by  the  handle  ;  the  point  of  the  blade  is  placed  upon  the  posteri- 
or commissure,  and,  while  backward  pressure  is  made,  the  speculum 
is  passed  into  the  vagina.  Care  should  be  taken  not  to  touch  the 
meatus  urinarius.  The  free  blade  is  then  grasped  with  the  right  hand 
by  the  nurse  or  assistant,  while  with  the  left  she  raises  and  supports 
the  natis  and  labium  on  the  upper  or  right  side.  The  position  of  the 
one  who  holds  the  speculum  should  be  with  the  left  side  toward  the 
patient,  the  lingers  of  the  right  liand  surrounding  the  blade,  while  the 
thumb  rests  in  the  inside  of  the  blade.  The  elbow  should  rest 
against  the  side,  as  a  point  of  purchase  to  give  ability  to  make  steady 
traction.  The  left  arm  should  rest  upon 
the  right  hip  of  the  patient,  while  the 
hand  supports  the  labium  and  natis  to  keep 
them  out  of  the  way  (Fig.  6).  Careful 
training  is  required  to  enable  one  to  hold 
the  speculum  properly.  The  chief  and 
essential  requirement  is  to  maintain  the 
instrument  for  any  desired  length  of  time 
in  the  position  in  which  the  operator  may 
choose  to  place  it.  The  objects  to  be  at- 
tained by  the  use  of  the  speculum  are,  to 
distend  the  vulva  by  making  traction  upon 
the  posterior  commissure,  and  at  the  same 
time  to  draw  the  whole  floor  of  the  pelvis  or  perinseum  backward 

toward  the  sacrum,  away  from  the  pelvic 
organs  above,  which,  from  the  position  of 
the  patient,  gravitate  toward  the  abdomi- 
nal cavity.  By  these  means  the  vagina  is 
distended  by  atmospheric  pressure,  which 
gives  space  for  the  admission  of  light,  and 
room  for  inspection  or  manipulation  in 
operating.  These  facilities  can  be  extend- 
ed by  changing  the  position  of  the  specu- 
lum in  the  following  manner:  The  as- 
sistant who  holds  the  instrument  can,  by 
rotating  the  hand,  cause  the  point  of  the 
blade  in  the  vagina  to  describe  the  arc  of  a  circle  (Fig.  Y).  Bj 
moving  the  hand    forward,  the  blade  is  made  to  point  backward 


Fig.  7. — The  raovcmcnts  of  the 
speculum.     First  movement. 


Second  movement. 


14 


DISEASES  OF   WOMEN. 


toward  the  rectum;  and  l)j  moving  the  liand  Imckward,  the  blade 
is  caused  to  point  forward  (Fig.  8) ;  and,  finally,  l>y  raising  or  lower- 
ing the  hand,  the  speculum  is  made 
to  reflect  tlie  light  upward  or  down- 
ward to  either  the  u])perorlower  side 
of  the  vagina,  according  to  the  re- 
quirements of  the  examiner  ( Fig.  9 j. 
At  the  same  time  that  all  these 
changes  of  position  are  being  made, 
the  re(iuire(J  traction  upon  the  pe- 
rinseum  can  be  maintained. 

In  using  the  Cusco  speculum, 
the  position  of  the  patient  is  the 
same  as  for  examination  by  the 
touch.  The  Labia  are  separated  with  the  left  hand,  and  the  instru- 
ment introduced  with  the  blades  closed,  the  dii-ection  of  introduction 
being  downward  and  inward.  When  the  speculum  is  in  position  the 
blades  are  separated. '  There  is  quite  often  difficulty  in  bringing  the 
cervix  into  view  through  this  instrument.  This  can  usually  be  avoid- 
ed by  getting  the  point  of  the  posterior  blade  well  under  the  cervix 
before  separating  the  blades.  This  speculum  is  principally  used  in 
the  treatment  of  the  simpler  diseases  of  the  cervix  uteri,  when  an  as- 
sistant can  not  be  procured  to  hold  a  Sims's  speculum.  As  a  means 
of  investigation  it  is  quite  limited  in  its  use. 


Fig.  9. — The  third  movement. 


THE   UTERINE   SOUND   AND   PROBE. 

There  are  three  kinds  of  sounds :  Simpson's,  which  is  made  of 
hard  metal,  and  maintains  an  unchangeable  shape ;  Sims's,  which  is 
of  soft  metal,  and  can  be  bent  or  molded  to  any  curve ;  and  a  third, 
which  is  elastic  and  bends  on  the  slightest  pressure,  Init  by  its  elas- 
ticity regains  its  original  shape.  There  are  two  varieties  of  the  lat- 
ter :  that  made  of  elastic  material  like  whalebone  or  rubber,  and  a 
metallic  one,  rendered  elastic  by  a  spiral  arrangement  in  its  mechan- 
ism, known  as  Jenks's.  The  stiff,  unyielding  sound  of  Simpson  is 
ten  inches  long,  being  smallest  at  the  end,  and  having  a  bulb  two  and 


sc 


-  "•  I     ■     !■  i'' 


QfoTIEMANNScCo. 

Fig.  10. — Simpson's  probe. 


a  half  inches  from  the  point.     It  is  graduated  in  quarter-inches  up 
to  six  inches  (Fig.  10).    It  is  seldom  used  now,  except  in  a  modified 


METHODS   OF   OBSERVATION. 


15 


form.  It  is  difficult  to  use  because  its  shape  can  not  be  adapted  to 
diiierent  eases ;  and  it  is  dangerous,  from  the  fact  that  it  -svill  not 
bend  to  light  pressure. 


Fig.  11. — Sims's  probe. 

Sims's  probe  is  made  of  soft  copper  or  pure  silver,  both  of  which 
metals  have  the  quality  of  being  easily  molded.  It  is  like  the  ordi- 
nary probe  used  in  general  surgery,  only  longer  and  a  httle  thicker, 
and  is  provided  with  a  handle  (Fig,  11). 

The  ]3robe  which  is  most  generally  used,  and  the  one  which  I 
prefer  for  ordinary  use,  is  the  same  as  Sims's,  only  thicker.  It  is 
stiff  enough  to  sustain  all  requisite  pressure,  and  yet  can  be  easily 


G.T\eW\NUU8KGQ. 
Fig.  12. — Whalebone  sound. 

molded  to  any  curve.  In  practice  it  is  well  to  be  provided  with 
this  one  as  well  as  that  of  Sims. 

The  elastic  probe  is  the  same  in  form  as  Sims's,  but  is  made  of 
rubber,  gum-elastic,  or  whalebone  (Fig.  12). 

The  sound  of  E.  W.  Jenks  is  hollow  and  spiral  for  a  distance  of 
two  thirds  from  the  pointed  end.  This  spiral  arrangement  gives  it 
flexibility.  It  is  also  graduated  and  provided  with  a  sliding  sheath 
which  is  very  convenient  in  measuring  the  depth  of  the  uterus,  the 


Fig.  13. — Jenks's  sound. 


arrangement  being  such  that  the  examiner  can  run  the  sheath  to- 
ward and  away  from  him,  the  figures  at  the  end  of  the  sheath  near- 
est the  handle  giving  the  measurement  of  the  distance  from  the 
point  to  the  distal  end  of  the  sheath  (Fig.  13). 

The  sound  or  probe  should  only  be  used  after  the  position  of  the 
uterus  has  been  ascertained  l)y  a  digital  examination,  and  its  sensi- 
tiveness tested  as  far  as  that  can  be  by  the  touch.  It  is  very  impor- 
tant to  know  the  position  of  the  uteras  and  its  relations  to  the  other 
organs,  in  order  that  the  sound  may  be  curved  to  suit  the  direction 


16  DISEASES   OF   WOMEN. 

of  the  canal  of  the  uterus,  and  to  suggest  the  direction  in  wliicli  the 
instiinnent  .should  he  guided.  There  are  two  ways  of  probing  the 
uterus :  In  the  one,  the  patient  is  placed  upon  the  back,  and  the  fin- 
ger of  the  examiner  is  carried  up  to  the  os  uteri ;  the  sound  is 
then  guided  along  the  linger  until  it  enters  the  canal,  when  it  is 
passed  to  the  fundus,  the  handle  being  depressed  to  make  the  sound 
correspond  to  the  direction  of  the  canal  of  the  uterus.  The  other 
way  is  to  expose  the  uterus  with  Sims's  speculum,  and  to  pass  the 
sound  with  the  aid  of  the  eye.  This  latter  method  is  the  easiest 
and  safest,  and  gives  at  least  as  much  information  as  the  one  first 
described.  The  vaginal  walls  being  distended  b}^  the  speculum, 
the  instrument  is  free  to  accommodate  itself  to  the  direction  of  the 
canal  of  the  uterus,  and,  aided  by  sight,  the  os  uteri  can  be  found  at 
once.  Safety  in  using  the  sound  does  not  depend  so  much  upon  the 
touch  which  guides  the  instrument  to  the  uterus  as  upon  the  hand 
that  holds  and  passes  it  into  that  organ.  There  are  few  who  acquire 
the  perfection  of  touch  to  guide  the  sound  into  the  unseen  uterus 
without  using  force,  which,  though  very  slight,  may  cause  mischief. 

In  sounding  or  probing  the  uterus  in  any  way,  force  should  not 
be  used.     Tliis  rule  should  never  be  violated. 

The  Sound  and  Palpation  Combined. — In  this  method  of  examina- 
tion the  sound  is  passed  by  touch,  with  the  patient  upon  the  back, 
and,  while  it  is  in  the  uterus,  it  is  held  with  one  hand;  the  other 
hand  is  placed  upon  the  abdomen,  and  downwarrl  pressure  made  until 
the  uterus  is  felt.  The  uterus  is  then  moved  by  the  sound,  and  the 
movements  are  detected  by  the  hand  upon  the  abdomen.  The  in- 
formation obtained  in  this  way  will  be  noted  farther  on. 

The  Curette. — This  instrument  is  used  to  explore  the  cavity  of 
the  uterus  in  order  to  detect  any  abnormal  growths  which  may  be 
there,  and  also  to  remove  portions  of  such  growth  for  inspection,  in 
order  to  determine  their  character.  The  instrument  best  adapted  to 
this  purpose  is  made  upon  the  pi-inciple  of  the  Recamier  curette.  It 
is  simply  a  scoop  of  small  size  with  a  stem  of  flexible  copjier  or  sil- 
ver, the  object  of  this  flexibility  being  to  enable  the  investigator  to 
bend  or  curve  it  to  suit  the  position  of  the  uterine  canal,  and   also 


Fig.  14. — Skene's  curette. 


G    TIEMANN  &C0. 


that  it  may  bend  before  doing  any  damage  to  the  endometrium  if 
undue  force  is  inadvertently  used  (Fig.  14). 

The  curette  is  introduced  through  a  Sims's  speculum  in  the  same 


METHODS   OF   OBSERVATION. 


17 


manner  as  the  sound,  and  when  once  witJiin  the  cavity  of  the  uterus 
it  is  passed  over  the  surfaces  of  the  endometrium,  and  if  any  pro- 
jections are  detected  a  portion  can  be  scraped  oli"  and  removed  for 
inspection.  The  further  use  of  the  curette  will  be  again  described, 
in  connection  with  the  treatment  of  diseases  of  the  uterus. 

The  Aspirator. — This  instrument  is  employed  to  investigate  the 
contents  or  composition  of  tumors  formed  in  the  pelvis.  When  the 
question  arises  whetlier  tbe  tumor  present  is  solid  or  fluid,  and  if 
fluid  what  the  character  of  the  fluid  is,  the  use  of  the  aspirator  will 
determine.  The  aspirator  used  in  general  surgery  answers  well ; 
still,  a  hypodermic  syringe,  larger  than  tlie  usual  size,  and  armed  with 
a  long,  slightly  curved  needle,  thick  enough  at  the  end  nearest  the 
syringe  to  give  it  strength  to  bear  pressure,  is  more  convenient. 

The  method  of  using  the  exploring  aspirator  is  as  follows :  The 
patient  is  placed  upon  the  back,  and  the  point  of  the  needle  is  guided 
to  the  part  to  be  examined,  and  is  then  thrust  into  the  mass  or  tu- 
mor; tbe  piston  is  tlien  drawn  out,  and  the  fluid,  if  any  be  pres- 
ent, is  examined. 

Uterine  Dilators. — When  it  is  necessary,  as  occasionally  hapjjens, 
to  dilate  the  cervical  canal  in  order  to  explore  tlie  cavity  of  tlie 


Fig.  15. — Hanks's  dilator. 


uterus,  resort  must  be  had  to  some  of  the  dilators.     These  are  of 
two  kinds :  The  first  consists  of  graduated  dilators,  which  can  be 


16. — Palmer's  dilator. 


passed  in  rapid  succession,  such  as  the  dilators  of  Hanks  (Fig.  15), 
and  the  instruments  with  expanding  blades  (Fig.  16).  These  are  in- 
tended to  produce  rapid  divulsion  to  the  required  extent.  The 
other  kind  acts  by  the  swelling  of  the  material  of  which  they  are 
made.  Of  these  tents  the  compressed  sponge  (Fig.  17),  sea-tangle, 
and  tupelo  (Fig.  18)  are  in  general  use. 

It  is  seldom  that  tents  are  required  for  purposes  of  examination 
3 


18  DISEASES  OF   WOMEN. 

only ;  the  dilators  mentioned  answer,  as  a  rule.  Tliev  act  more 
promjjtly,  and  are  less  likely  to  cause  after-trouble  if  dilatation  is  not 
carried  to  an  extent  wliicli  is  seldom  necessary  for  purposes  of  ex- 
amination.    Tents  are  to  be  avoided  if  possible,  because  of  the  suffer- 


FiG.  17.— Sponge  tents.  Fig.  18.— Tupelo  tents 


ing  they  cause,  and  the  danger  of  inflammation  and  blood-poisoning, 
both  of  which  misfortunes  have  followed  their  use.  They  expand 
slowly,  and  cause  irritation  and  pain,  which  must  be  endured  for 
hours  before  they  accomjjlish  their  work.  Acting  thus  like  foreign 
bodies  and  powerful  irritants,  they  are  not  without  danger.  The 
dilators  act  more  promptl}^  and  are  less  likely  to  induce  inflamma- 
tion, and,  although  they  cause  pain  and  irritation,  these  are  of  short 
duration. 

The  Concave  Mirror. — This  is  commonly  known  as  the  head-mirror, 
and  is  used  in  the  practice  of  laryngoscopy.  It  is  also  of  much  use 
in  speculum  examinations  when  a  good  light  can  not  be  obtained. 
In  emergencies  occurring  at  night,  the  mirror  enables  the  surgeon  to 
use  artificial  light  with  perfect  satisfaction.  Placing  a  lamp  by  the 
side  of  the  ])atient  in  front  of  tlie  examiner,  the  light  can  be  reflected 
into  the  vagina  so  as  to  expose  the  parts  in  a  very  perfect  way. 
Facility  in  the  use  of  tin's  mirror  should  be  ncquircd,  as  it  is  at  times 
indispensable. 

The  Microscope. — A  careful  scrutiny  of  the  minute  structure  of 
pathological  specimens  is  always  necessary  to  complete  diagnosis, 
hence  the  microscope  should  be  placed  high  in  the  list  of  means  for 
exact  observation  and  investigation.  All  that  need  be  done  in  this 
connection  is  to  remind  the  reader  of  the  fact.  A  knowledge  of 
the  microscope  and  its  use  must  be  obtained  elsewhere.  The  prog- 
ress in  microscopic  investigation  has  been  go  great  that  many  men 
in  active  practice  have  neither  the  time  nor  the  ability  to  make  their 
own  microscopic  investigations.  When  such  is  the  case,  the  duty  of 
the  gynecologist  clearly  is  to  seek  the  aid  of  the  microscopist  that  he 
may  obtain  through  him  the  required  information. 


METHODS  OF  OBSERVATION.  19 

Anaesthesia. — There  are  certain  cases  that  can  not  be  examined 
without  being  ansBsthetized.  When  there  is  great  tenderness  of 
tlie  pelvic  organs,  and  the  abdominal  muscles  are  in  a  condition  of 
spasm,  which  render  the  examination  wholly  impossible  or  suffi- 
ciently unsatisfactory  to  leave  a  doubt  in  the  mind,  then  ether  should 
be  given  to  the  extent  of  complete  anaesthesia.  The  relaxation  wliich 
this  aifurds  simpliiies  all  investigations  in  a  very  marked  degree.  In 
the  investigation  of  the  pelvic  organs  of  insane  women  and  in  vir- 
gins who  certainly  require  examination  yet  can  not  submit,  the 
nitrous-oxide  gas  is  of  great  value.  It  acts  quickly  and  pleasantly, 
and  has  none  of  the  effects  during  or  after  its  administration  which 
are  so  distressing  to  those  of  sound  mind  and  horrifying  to  the 
insane. 

The  mode  of  administering  it  is  with  the  apparatus  used  by  den- 
tal surgeons  to  whom  we  are  indebted  for  perfecting  the  apparatus 
for  giving  this  anaesthetic.  The  gas  is  condensed  in  a  strong  cylin- 
der which  holds  one  hundred  gallons.  By  a  valve  arrangement  it  is 
permitted  to  escape  into  a  rubber  bag,  from  which  it  is  inhaled. 
The  inhaler  is  an  ingenious  arrangement  by  which  the  act  of  inspi- 
ration opens  a  valve  that  permits  the  gas  to  be  drawn  from  the 
bag,  while  the  act  of  expiration  closes  the  valve  in  the  supply-tube, 
and  opens  another  valve  for  the  escape  of  the  impure  air.  There  is 
still  another  valve  under  the  control  of  the  operator,  which  admits 
air  with  the  gas,  so  that  when  the  patient  is  fully  ansesthetized  the 
gas  can  be  diluted  with  air  in  sufficient  quantity  to  keep  up  the 
anaesthesia.  The  cylinder  of  condensed  gas  and  the  inhaler  are  put 
U]3  in  a  case  convenient  to  carry.  The  mechanism  of  this  apparatus 
can  be  more  easily  comprehended  by  examination  than  by  descrip- 
tion, and  a  little  practice  will  enable  any  one  to  use  it. 

To  be  able  to  recognize  the  normal  and  pathological  conditions 
which  are  revealed  by  the  means  described  requires  much  practice. 
It  greatly  aids  in  obtaining  that  practice — in  fact,  it  is  quite  neces- 
sary— to  keep  clearly  in  mind  what  to  look  for.  In  order  to  facilitate 
the  memorizing  of  the  objects  to  I)e  investigated,  I  have  arranged  the 
signs  under  each  of  the  various  means  of  obtaining  them  as  follows : 

Vaginal  Touch. — Position,  size,  shape,  and  density  of  the  uterus. 

Size  and  shape  of  the  os  externum. 

Presence  or  absence  of  discharge  from  cervix. 

Condition  of  vaginal  walls,  perineal  body,  and  recto-uterine  space. 

State  of  the  rectum  and  lower  portion  of  sac  of  Douglas. 

Position  of  the  bladder  and  urethra  as  indicated  through  the  an- 
terior vaginal  wall. 


20  DISEASES   OF   WOMEN. 

Presence  or  absence  of  lixation  of  pelvic  organs ;  swelling  or  tu- 
mors in  the  sac  of  Douglas  or  broad  ligaments. 

Ti'iidenic'ss  at  any  })art. 

Bimanual  Touch, — Size,  form,  and  position  of  the  body  of  the 
uterus. 

Tenderness  and  mobility  of  tlie  uterus  and  other  organs  and 
tissues. 

Position  and  state  of  the  Fallopian  tubes  and  ovaries. 

Condition  of  the  bladder. 

Presence  of  neoplasms  and  their  relation  to  the  pelvic  organs. 

Products  of  inflammation,  their  location  and  character. 

Rectal  Touch. — Condition  of  the  rectum,  posterior  surface  of  the 
uterus,  broad  ligaments.  Fallopian  tubes,  and  ovaries ;  conlirmation 
or  correction  of  signs  obtained  by  bimanual  examination, 

Vesico-rectal  Touch. — AbscTice  of  the  uterus  from  its  normal 
position  in  inversion  of  the  uterus,  entire  absence  of  the  uterus; 
aid  to  diagnosis  in  women  who  are  too  fat  to  permit  tlie  bimanual 
examination. 

Vesico-vaginal  Touch. — Changes  in  the  position  of  the  bladder 
and  urethra.     Results  of  disease  in  the  vesico-vaginal  septum. 

Palpation. — Form,  size,  and  density  of  tumors  or  products  of  in- 
tiammation  felt  tlirough  the  abdominal  walls. 

Percussion. — Density  of  morbid  parts, 

^Normal  resonance. 

Relations  of  the  above. 

Palpation  and  Percussion  Conjoined. — Fluctuation,  density,  or 
elasticity  of  morbid  parts. 

Speculum. — Apj)earance  of  mucous  membrane  of  cervix  uteri 
and  vagina. 

Signs  of  inflammation  of  mucous  membrane. 

Relations  of  the  cervix  to  the  vagina. 

Form  of  os  externum. 

Character  of  secretions. 

Signs  of  injuries  to  the  cervix  and  vagina. 

Nature  of  new  growths  suggested  by  their  appearance, 

Sound  and  Probe. — Direction  of  the  canal  of  the  cervix  and  cav- 
ity of  the  body  of  the  uterus,  in  relation  to  their  normal  position  in 
the  pelvis. 

Relation  of  the  canal  of  the  cervix  and  cavity  of  the  body  to  each 
other. 

Straight,  deflected,  or  tortuous  state  of  the  cavity  of  the  uterus. 

Long  and  transverse  diameters  of  the  ca-snty  of  the  uterus. 


METHODS   OF   OBSERVATIOK 


21 


Ciiliber  of  tlie  cervical  canal,  os  cxternutn,  and  os  internum. 

Degree  of  sensitiveness  of  the  different  portions  of  the  cavity  of 
the  uterus. 

Sound  and  Palpation  Combined. — Displaced  uterus  may  be  raised 
up  to  meet  the  touch  of  the  hand  upon  the  abdomen  for  examina- 
tion. 

Mobility  of  the  uterus  with  or  without  moving  abnormal  growths 
in  the  pelvis  or  lower  portion  of  the  abdomen. 

Curette. — Presence  or  absence  of  growths  or  tumors  in  the  uteras. 

Removal  of  portions  of  growths  from  the  cavity  of  the  uterus 
for  inspection. 

Aspiration. — Abstraction  of  fluid  (encysted  or  otherwise)  for  in- 
spection. 

Dilators,  tents,  anaesthetics  and  head-mirror  as  aids  with  other 
means  of  exploration. 


Fig.  18a. — Ether-inhaler.  Its  principle  is  the  same  as  that  of  the  nitrous-oxide  appara- 
tus. The  reservoir,  n,  in  which  the  ether  is  vaporized,  is  separated  from  the  mouth- 
piece, A,  by  the  long  rubber  tube.  The  valves,  e,  of  the  mouth-piece  permit  the 
expired  air  to  escape  without  coming  in  contact  with  the  ether-vapor.  The  valve,  D, 
enables  the  an<esthetizer  to  administer  pure  air  or  pure  ether,  or  any  proportion  of 
air  and  ether.  The  advantages  of  the  apparatus  are  that  the  ether-vapor  is  warmed, 
that  reinspiration  of  expired  air  is  avoided,  and  that  the  ether  may  be  diluted  with 
air  to  maintain  the  required  anaesthesia.  The  stage  of  violent  excitement  caused  by 
partial  suffocation  is  avoided,  and  prolonged  anesthesia  can  be  maintained  without 
the  slightest  imperfection  of  aeration  of  the  blood. 


CHAPTER  II. 


DEVEL0P3IEXT    OF   THE    SEXUAL    ORGANS. 


The  Fallopian  tubes,  uterus,  and  vagina  are  developed  from  two 
primary  elements  known  as  Miiller's  filaments.  These  filaments 
when  first  visible  in  the  embrvo  are  solid,  and  are  situated  on  either 
side  of  the  vertebral  column,  a  little  in  front  of  and  on  the  inner  side 
of  two  other  primary  elements,  the  Wolffian  bodies.  Tlie  changes 
which  take  place  in  Miiller's  filaments  during  the  evolutions  of  de- 
velopment are  as  follows :  From  solid  libers,  slightly  enlarged  and 
club-shaped  at  their  uj)per  ends,  cavities  are  formed,  and  these  be- 
come canals.  Their  lower  ends  ap])roximate  and  coalesce,  from 
below  upward,  less  than  half  their  length.  This  change,  which 
takes  place  between  the  ends  of  the  sixth  and  eighth  weeks  of 

fcetal  life,  is  repre- 
sented in  Figs.  19 
and  20.  At  this 
stage  of  develop 
ment,  Miilk'r's  ducts 
are  separated  by  a 
se])tuni  fonned  from 
their  coalescent  walls, 
so  that  the  united 
portion  shows  a  right 
and  left  cavity. 
These  two  cavities 
are  soon  converted 
into  one,  the  septum 
disappearing  from 
below  upward  throughout  the  whole  of  the  united  portion  of  the 
ducts.  The  lower  single  canal  thus  formed  is  the  rudimentary  vagina 
and  uterus,  while  the  two  upper  ends  of  Miiller's  ducts  form  the 
Fallopian  tubes  (Fig.  21).     From  tliis  time  to  the  fifth  month  there 


19. — Mullcr's 
ducts. 


Fig.  20. — Coalescence  of 
ducts. 


Fio.  21. — Disappearance  of 
septum. 


Fig.    22.  —  Appearance   of 
fundus  and  cervix. 


DEVELOPMENT   OF   THE   SEXUAL   ORGANS. 


23 


is  an  increase  of  tissue,  especially  in  the  upper  portion  of  the  canal, 
which  renders  the  distinction  between  the  vagina  and  uterus  appar- 
ent. The  upper  ends  of  Miiller's  ducts  expand  and  become  slightly 
fimbriated  at  their  extremities.  The  upper  portion  of  the  uterus  at 
this  time  is  bifurcated  and  forms  the  two  horns  between  which  the 
fundus  is  subsequently  developed.  Fig.  22  shows  the  organs  at  this 
stage  of  development.  In  the  sixth  and  seventh  months  the  uterus 
increases  in  size,  especially  in  the  cervical  portion,  which  at  this 
stage  is  much  larger  than  the  body.  There  is  also  an  increase  of 
tissue  between  the  horns  of  the  uterus  which  rendere  their  diverg- 
ence less  marked.  The  rugose  arrangement  (palma  plicata)  of  the 
rudimentary  mucous  membrane  of  the  cavity  of  the  uterus  extends 
very  nearly  to  the  fundus,  its  folds  running  outward  to  the  uterine 
orilices  of  the  Fallopian  tubes.  Ele- 
vations appear  in  rows  upon  the  mu- 
cous membrane  of  the  vagina  which 
are  the  rudiments  from  which  the 
transverse  folds  are  subsequently  de- 
veloped. During  the  eighth  and  ninth 
months  the  thickness  of  the  walls  of 
the  body  of  the  uterus  increases,  the 
fundus  becomes  more  prominent  and 
rounded,  but  up  to  the  time  of  birth 
the  cervix  is  larger  than  the  body  of 
the  uterus.  At  the  time  of  birth  the 
primary  development  of  the  uterus  is  complete,  and  it  changes  very 
little  in  form  from  that  time  until  the  period  of  pubei'ty.     The  size 

and  appearance  of  the  infantile  uterus  are 
shown  in  Fig.  23.  The  cavity  of  the  uter- 
us and  the  arrangement  of  its  mucous 
membrane  are  represented  by  Fig.  24. 
Fig.  25  gives  a  side-view  of  the  uterus 
and  vagina,  and  shows  their  relations  to 
each  other.  At  this  time  the  cer\dx  pro- 
jects but  little  into  the  vagina. 

From  the  time  of  birth,  when  primary 
development  is  complete,  up  to  the  period 
of  puberty,  the  uterus  undergoes  very  lit- 
tle change  except  during  the  second  den- 
tition. At  that  time  the  body  increases  in 
size,  becoming  more  nearly  equal  to  the 
invagination.  cervix.      The    palma   plicata    disappears 


Fig.  23.— Infan- 
tile uterus. 


Fig.  24.  —  Palma 
plicata  extend- 
ing nearly  to 
fundus. 


Fig.    25. — Infantile   uterus,  an- 
tero-posterior  section,  scant 


24: 


DISEASES   OF    WOMEN. 


from  the  body  of  the  uterus,  excepting  one  longitudinal  fold.  The 
uterus  gradually  descends  into  the  pelvic  cavity  and  the  cervix  is 
projected  down  into  the  vagina  a  little  farther.  From  this  time  no 
changes  occur  worthy  of  notice  until  puberty,  when  secondary  de- 
veloj)ment  takes  place. 

Secondary  development  consists  in  a  general  increase  in  the  siee 
of  the  uterus,  especially  in  the  body  and  fundus,  which  become  much 
larger  than  the  cervix.  The  length  of  the  uterus  is  increased.  The 
walls  become  thicker  and  firmer.  The  last  trace  of  the  palma  pli- 
cata  disappears  from  the  mucous  membrane  of  the  cavity  of  the 
body,  and  the  mucous  membrane  becomes  thicker  by  the  formation 
of  its  glandular  tissues.  In  this  way  the  uterus  attains  the  shape 
and  size  of  maturity.  Together  with  the  changes  in  size  and  form 
comes  a  change  of  position.  The  uterus  descends  into  the  pelvis  and 
complete  invagination  of  the  cervix  occurs. 

Fig.  26  shows  the  general  appearance  of  the  mature  uterus  in 
outline,  and  Figs.  27  and  28  re^Dresent  the  relations  in  which  the 


Fig.  26. 


Fig.  28. 


Fig.  27. 

Figs.  26-28. — Virgin  uterus  (Sappey)  :  26,  anterior  view;  27,  median  section;  28,  trans- 
verse section.  26.  1,  body;  2,  2,  angles;  3,  cervix;  4,  site  of  the  os  internum ;  o, 
vaginal  portion  of  the  cervix;  6,  external  os.  27.  1,  1,  anterior  surface;  2,  vesico- 
uterine ciil-dt'-sac  ;  3,  3,  posterior  surface ;  6,  isthmus ;  7,  cavity  of  body ;  8,  cavity 
of  the  cervix;  !>,  os  internum;  10,  anterior  li])  of  os  externum ;  11,  posterior  lip. 
28.  1,  cavity  of  body;  4,  4,  cornua ;  .5,  os  internum;  6,  cavity  of  cervix;  7,  arbor 
vit<c  of  the  cervix ;  8,  os  externum. 

cervix  and  vagina  stand  to  each  other.  By  com]">aring  Figs.  23  and 
25,  which  illustrate  the  infantile  uterus,  with  Figs.  26  and  27,  the 
difference  between  the  results  of  primary  and  secondary  develop- 
ment will  be  fully  comprehended. 


DEVELOPMENT  OF  THE  SEXUAL  ORGANS. 


25 


MALFORMATIONS   OF   THE   UTERUS. 

The  malformations  of  the  uterus  are  naturally  divisible  into  two 
classes  :  those  that  occur  during  embryonic  life,  and  those  that  occur 
at  puberty,  the  period  when  secondary  development  takes  place. 
The  lirst  class  embraces  the  greatest  variety.  Nearly  all  of  these 
malformations  are  due  to  arrest  of  development  at  different  stages  of 
that  process.    The  malformations  most  frequently  seen  are  the  uterus 


a 

Fig.  29. — Double  uterus  and  vagina  from  a  girl  aged  nineteen  (Eisenmann) :  a,  double  vagi- 
nal orifice  with  double  hymen. 

bipartis,  uterus  duplex,  uterus  unicornis,  uterus  bicornis,  uterus  bi- 
fundalis  unicollis,  and  rudimentary  uterus,  generally  known  as  ab- 
sence of  the  uterus.  A  very  rare  condition  has  been  described  as 
hypertrophy  of  the  uterus,  and  classed  with  the  malformations.  It 
is  really  not  a  malformation,  but  a  complete  development  of   the 


2U 


DISEASES  OF    WOMEN. 


uterus  during  infantile  life.    When  the  first  evolution  in  the  process 
of  development — i.  e.,  the  union  or  coalescence  of  Miiller's  ducts — 


Fig.  30. — Uterus  unicorai?  from  a  young  child,  posterior  aspect  (Pole):  6,  right  Fallopian 
tube;  c,  left  Fallopian  tube    exceptionally  present ;  d  J,  ovaries  ;  c,  bladder  (Courty). 

is  arrested,  and  each  duct  grows  bv  itself,  the  result  is  the  uterus 
bipartis  (Fig.  33). 

The  uterus  duplex  is  formed  by  the  coalescence  of  the  ducts, 
with  arrest  of  absorption  of  the  central  wall.  The  development 
goes  on,  so  that  in  time  the  whole  organ  is  larger  than  the  n(jrmal 
uterus,  but  it  is  divided  into  two  by  the  central  wall  (Fig.  29). 
Uterus  unicornis  is  produced  by  a  complete  arrest  of  development 
of  one  of  the  ducts  at  the  part  which  should  form  one  half  of  the 
body  and  fundus  of  the  uterus  (Fig.  30).  The  uterus  bicornis  occurs 
as  the  result  of  non-union  of  that  part  of  the  ducts  which  forms  the 


TuSa 


Fransen 


Fig.  :>]. — Uterus  bicornis  unicollis  (Winckel). 

body  and  fundus  (Fig.  31).  The  uterus  bif undalis  unicollis  is  formed 
by  the  same  error  of  development  as  that  which  produces  the  uterus 
bicornis  and  double  uterus  with  the  following  diiference  :  In  the 


DEVELOPMENT   OF   THE   SEXUAL   ORGANS. 


27 


uterus  bifuudalis  (Fig.  32)  the  liorDS,  though  not  united,  are  well  de- 
veloped and  present  outlines  more  nearly  like  the  normal  body  of 
the  uterus  and  the  septum 
formed  by  the  union  of  the 
ducts  at  the  part  which  forms 
the  cervix.  In  this  it  differs 
from  the  uterus  duplex  (Fig. 
33).  Entire  absence  of  tlie 
uterus  is  perhaps  unknown, 
unless  in  monstrosities  in 
whom  the  lower  part  of  the 
trunk  is  wanting.  Rudiment- 
ary uterus  is  seen  occasionally. 
As  most  frequently  found, 
there  is  a  very  small  cervix  slightly,  if  at  all,  invaginated,  and  in 
place  of  the  body  of  the  uterus  one  or  two  small  solid  masses  are 


Fig.  32. — Uterus  bifundalis  unicollis. 


Fig.  33. — Uterus  duplex  (Cruvcilliicr).    Left  walls  developed  in  consequence  of  pregnancy. 

found  from  a  quarter  to  half  an  inch  in  thickness  and  about  the 
same  in  length. 

The  effect  of  these  malformations  as  manifested  during  func- 


28  DISEASES  OF   WOMEN. 

tioiial  life  is  (juite  remarkable.  lu  some  there  is  not  tlie  slightest 
deviation  from  health  in  the  function  of  the  sexual  organs.  In 
othere  the  results  are  verv  disastrous.  This  practicallv  gives  two 
classes  of  uiaU'ormations  according  to  the  elfect  they  have  ui)on  the 
healtli  and  usefulness  of  the  subject.  In  the  one  class  the  malfor- 
mation does  not  materially  aifect  the  function  of  the  uterus,  while  in 
the  other,  the  functional  action  is  always  imperfect — sometimes  im- 
possible. The  cases  of  simple  deformity,  in  which  there  are  suffi- 
cient development  and  growth  of  one  or  both  elements  of  the  uterus 
to  make  the  organ  functionally  competent,  have  no  ill  etfect  uj)on 
the  general  usefulness  and  welfare  of  the  individual.  The  follow- 
ing case  will  illustrate  this  : 

Double  Uterus  and  Vagina. — A  married  lady,  thirty-two  years  of 
age,  who  had  borne  three  children  and  nursed  them,  called  upon  me 
for  advice  regarding  a  leucorrhoea  which  had  troubled  her  since  the 
birth  of  her  last  child.  Iler  general  health  had  always  been  ex- 
cellent. Upon  making  a  digital  examination,  I  found  the  vagina 
normal  and  also  the  cervix,  excepting  tliat  one  side  of  the  cervix 
was  closely  united  to  the  vaginal  wall  throughout  its  entire  length. 
On  the  left  side  of  the  vagina  high  up  I  found  a  hard  mass  which 
was  also  noticed  on  making  bimanual  exploration.  The  first  im- 
pression was  that  she  had  suffered  from  a  pelvic  cellulitis,  and  that 
the  mass  on  the  left  side  was  the  remains  of  its  products.  This 
idea  was  given  up  at  once  on  finding  that  the  patient  gave 
no  history  of  any  pelvic  infiammation.  I  then  susj)ected  that 
there  might  be  a  fibroid  in  the  left  side  of  the  uterus,  which, 
by  extending  the  entire  length  of  the  cervix,  had  pushed  the 
vaginal  wall  before  it.  A  speculum  examination  revealed  a  ca- 
tarrh of  the  cervical  canal.  The  uterus  had  the  usual  appearance 
of  one  that  had  borne  children,  and  the  cervix  was  nonnal  in  shape 
and  position,  except  for  the  peculiar  relations  of  the  cervix  and 
vagina  on  the  left  side,  which  were  noticed  during  the  examination 
with  the  touch.  Just  \\'ithin  the  labium  minus  on  the  left  side,  a  pe- 
culiar fold  of  the  vaginal  wall  was  noticed  runnine:  transverselv. 
On  raising  this  fold  with  the  point  of  the  sound  it  w^as  found  to  be 
a  septum,  and  there  was  also  discovered  another  vagina  to  the  left  of 
it.  Using  a  smaller  Sinis's  speculum  to  distend  this  vagina,  I  found 
the  other  cervix  which  had  all  the  characteristics  pertaining  to  a  nul- 
lipara. The  passage  of  a  sound  showed  that  the  canal  of  the  uterus 
on  the  left  side  was  not  quite  so  long  as  the  one  on  the  right.  It 
was  then  clearly  evident  that  the  patient  had  a  double  utenis  and 
vagina,  and  that  the  right  uterus  had  borne  three  children,  while 


DEVELOPMEx\T   OF   THE   SEXUAL   ORGANS.  2i) 

the  left  uterus  was  a  virgin  one.  She  was  attended  in  her  conliue- 
ments  by  tliree  different  physicians,  none  of  whom  made  any  refer- 
ence to  this  malformation,  and  it  is  fair  to  suppose  that  none  of 
them  discovered  it. 

This  case  is  of  interest  as  showing  the  fact  that  some  of  the  mal- 
formations do  not  in  any  way  affect  the  function  of  the  uterus  nor 
the  general  health  of  the  subject. 

When  there  is  malformation,  and  the  growth  of  the  utenis  falls 
so  far  short  of  the  normal  type  that  functional  activity  is  impos- 
sible, the  results  are  often  very  unfortunate.  The  nature  of  this 
class  of  eases  bears  such  close  resemblance  to  those  in  which  there 
is  arrest  of  secondary  development  at  puberty,  that  they  may  be  con- 
sidered together  in  the  following  chapter. 


CHAPTEK  III. 

ARREST  OF  DEVELOPMENT,  AND  ENTIRE  ABSENCE  OF  FUNCTIONAL  ACTIV- 
ITY— ARREST  OF  DEVELOPMENT  AND  GROWTH  IN  THE  LATER  STAGES 
OF  EVOLUTION,  AND  THE  CONSEQUENT  IMPERFECTION  OF  FUNCTION. 

If  absence  of  the  uterus  or  a  rudimentarj  state  of  its  develop- 
ment is  associated  with  absence  or  a  rudimentary  state  of  the  ova- 
ries, there  is  no  tendency  to  functional  action,  and  the  individual 
may  not  suifer  in  consequence.  She  simply  remains  an  imperfect 
and  undeveloped  being.  But  when  the  ovaries  are  present  and 
functionally  active,  there  is  generally  a  tendency  to  menstruate  ;  and 
this  tendency,  unrelieved  by  a  menstrual  flow,  is  often  attended  wnth 
great  derangement  of  the  general  health  and  much  suiiering. 

The  first  evidence  of  this  malfoi-mation  from  arrest  of  develop- 
ment that  comes  to  the  notice  of  the  physician  is  derangement  of 
the  menstrual  function  in  some  form,  or  its  non-appearance  at  the 
proper  age.  On  this  account  it  will  be  Avell  to  discuss  in  a  general 
way  the  nature  and  characteristics  of  menstruation  before  giving  the 
history  of  its  derangements,  which  arise  from  lesions  of  structure 
resulting  from  imperfections  of  development  and  growth. 

Menstruation  has  been  the  subject  of  so  many  speculations  re- 
garding its  physiology,  that  it  would  be  unprofitable  to  enumerate 
them.  Suffice  it  for  our  present  purpose  to  state  that  when  the  utenis 
attains  its  normal  development  in  a  healthy  subject  it  becomes  j:)os- 
sessed  of  all  the  requisites  necessary  to  the  development  of  an  ovum  ; 
but  when  impregnation  does  not  follow,  the  mucous  membrane  of 
the  cavity  of  the  body  of  the  uterus  undergoes  degeneration,  either 
wholly  or  in  part,  and  is  exfoliated  in  a  granular  state.  This  degen- 
eration and  exfoliation,  according  to  some  obsen'crs,  involve  the 
whole  membrane  down  to  the  muscular  walls,  while  others  claim 
that  they  only  affect  the  epithelial  layer.  Be  this  as  it  may,  there  ap- 
pears to  be  a  general  agreement  among  the  authorities  of  the  ]^resent 
time  that  de-reneration  and  exfoliation  occur  to  an  extent  sufficient 


ARREST   OF   DEVELOPMENT.  31 

to  expose  the  smaller  blood-vessels  of  the  endometrium,  and  to  so 
weaken  their  walls  that  they  give  way  and  haemorrhage  follows. 

This  menstrual  flow  is  composed  of  blood  from  the  vessels,  with 
at  least  the  debris  of  the  degenerated  and  exfoliated  epithelium. 
The  flow,  which  lasts  for  days,  subsides,  the  mucous  membrane  is 
renewed,  and  the  same  high  state  of  anatomical  completeness  and 
functional  capability  is  restored,  when  another  menstruation  takes 
place,  and  so  this  function  is  repeated  over  and  over  again,  except 
when  suspended  during  pregnancy  or  lactation,  until  the  end  of 
functional  activity  at  forty-five  years  of  age  or  thereabout. 

During  the  period  of  functional  activity  of  the  sexual  organs, 
from  puberty  to  the  menopause,  menstruation  is  an  evidence  of 
health,  and  is  also  essential  to  health.  It  is  an  index  of  the  state  of 
the  sexual  system  and  also  of  the  general  health  of  mature  women. 
Hence  its  derangements  constitute  most  valuable  evidence  of  the 
presence  of  disease,  while  its  normal  recurrence  is  an  evidence  of 
health.  In  practice  it -is  best  to  study  this  function  by  its  character- 
istics, rather  than  by  theories  regarding  its  cause  or  the  reasons  for 
its  existence.  It  is  on  this  account  necessary  to  comprehend  its  nat- 
ural history ;  therefore,  I  propose  to  give  here  a  synopsis  of  the  con- 
ditions of  menstmation. 

The  laws  which  govern  this  function  of  menstruation,  as  given  in 
our  text-books,  are  so  varied  by  climate,  personal  peculiarities,  and 
the  conditions  of  life,  that  a  general  average  pertaining  to  these 
laws  is  about  all  that  can  be  obtained,  and  this  can  be  used  to  very 
little  advantage  in  practice.  Fortunately,  there  are  certain  rales 
which  apply  to  menstruation  with  great  uniformity,  and  these  should 
be  clearly  understood.  The  most  important  of  these  are  the  fol- 
lowing : 

1.  Menstruation  should  begin  at  puberty — i.  e.,  when  the  woman 
is  maturely  developed,  no  matter  what  the  age  may  be.  Increase  of 
size  may  take  place  by  growth  after  puberty,  but  all  the  organs  of 
the  body  should  be  completely  defined,  so  far  as  form  and  structure 
are  concerned,  before  the  function  of  menstruation  is  taken  up. 

2.  It  should  recur  at  regular  intervals  ;  about  every  twenty-eight 
days  is  the  average  time.  A  regular  periodicity  is  normal,  but  the 
duration  of  the  periods  often  differs  in  different  persons. 

3.  The  discharge  should  always  be  fluid  in  consistence  and  san- 
guineous in  color. 

4.  The  flow  should  continue  a  definite  length  of  time,  the  dura- 
tion depending  upon  the  habit  of  each  case ;  at  least  there  should 
not  be  any  great  deviation  from  this  rule. 


32  DISEASES  OF   WOMEN. 

5.  The  quantity  should  be  about  the  same  each  time. 
There  should  be  no  deviation  from  the  tirst  rule.  If  the  menses 
appear  before  development  is  complete,  both  in  the  sexual  organs 
and  the  general  system,  it  is  an  error  which  is  either  the  result  of 
<iisease  or  of  the  surroundings  of  the  patient,  and  generally  modifies 
unfavorably  her  future  life  unless  it  can  be  corrected.  The  same 
may  be  said  regarding  those  who  fail  to  menstruate  when  the  devel- 
opment and  growth  of  the  body  are  completed.  The  other  rules  re- 
garding the  recurrence,  duration,  quantity,  and  character  of  the  men- 
strual flow,  may  vary  in  diiferent  women,  but  they  should  be  uni- 
form and  regular  in  each  person.  Whatever  the  habit  may  be  that 
is  established  at  puberty  in  a  given  case,  that  habit  should  be  main- 
tained through  life.  Some  women  menstruate  systematically  from 
puberty  until  after  bearing  a  child,  then  they  take  up  a  different 
order  of  menstruation  in  regard  to  all  or  some  of  the  characteristics 
of  that  function.  That  is  normal,  but  it  is  the  only  well-marked 
change  in  habit  which  is  the  same  in  health. 

Obedience  to  these  laws  of  the  menstnial  function  implies  cer- 
tain conditions  that  are  necessary  to  the  fullillment  of  these  laws. 
These  may  be  briefly  stated  as  follows : 

1.  Maturity  of  development  of  all  the  organs,  both  of  the  general 
and  se.xual  systems,  and  a  fair  degree  of  health  of  all. 

2.  A  sutiicient  and  well-regulated  supjily  of  normal  blood  to  the 
sexual  organs. 

3.  Normal  structure  and  functional  activity  of  the  nei'ves  which 
preside  over  the  action  of  the  sexual  organs. 

4.  Conditions  of  life  favorable  to  general  health  and  reproduc- 
tion.    This  includes  food,  climate,  society,  and  occupation. 

Allusion  has  already  been  made  to  absence  of  the  uterus  and 
also  to  its  rudimentary  states  in  which  the  menses  never  appear,  and 
because  of  these  marked  anatomical  defects  and  absence  of  function 
nothing  can  be  done  by  the  gynecologist  in  the  Avay  of  improve- 
ment. 

There  remain  to  be  considered  cases  in  which  the  conditions  of 
menstruation  are  all  present  but  in  an  imperfect  degree,  so  that  men- 
struation, although  established,  is  performed  imjierfectly. 

ILLUSTRATIA'E   CASES. 

Uterus  Unicornis ;  Imperfect  Menstruation  and  the  Results. — A 

woman,  twenty-nine  years  of  age,  of  healthy  parents,  above  the 
average  size,  and  well  formed  generally,  had  enjoyed  excellent 
health  until  she  was  eighteen  years  of  age.     About  that  time  her 


ARREST   OF   DEVELOPMENT.  33 

iiiaramary  glands  became  well  developed  and  she  presented  all  the 
outward  characteristics  of  woman  physical  and  psychical.  She  then 
began  to  suffer  at  stated  periods  from  backache,  a  sense  of  fullness 
in  the  pelvis,  and  slight  leucorrluea.  In  a  day  or  two  after  these 
symptoms  came  on,  and  while  they  continued,  she  became  heavy 
and  sleepy,  and  had  a  feeling  of  fullness  in  th'j  head  and  slight  head- 
ache. These  attacks  lasted  several  days,  when  they  passed  off  and 
again  returned  about  every  month.  In  the  interval  her  health  was 
good  and  she  performed  her  duties  as  a  domestic.  Five  months  after 
the  first  time  that  these  symptoms  appeared,  and  while  she  was  suf- 
fering from  an  attack,  she  had  a  slight  menstrual  flow,  which  lasted 
less  than  twenty-foui-  hours,  and  appeared  to  alleviate  her  suffering. 
The  next  month  her  flow  returned  in  the  same  way,  but  all  her  symp- 
toms were  increased.  From  this  time  on  her  menstrual  flow  re- 
turned regularly,  but  did  not  increase  in  duration  or  quantity.  At 
each  recurring  menstrual  period  her  suffering  increased  in  severity 
until  she  was  obliged  to  give  up  her  duties  at  such  times.  On  one 
occasion  when  she  was  trying  to  do  her  work  while  suffering,  she 
was  exposed  to  cold  and  was  seized  with  an  inflammation — pelvic 
peritonitis,  no  doubt — and  was  taken  to  the  hospital,  where  she  re- 
mained for  three  months.  During  that  time  she  took  morphine  lib- 
erally. From  this  time  her  suffering  during  the  mensti'ual  period 
was  very  great,  sufficiently  so  to  keep  her  in  bed,  and  to  require 
large  doses  of  morphine  to  make  life  tolerable.  Another  attack  of 
pelvic  peritonitis  came,  and  again  she  was  sent  to  the  hospital  for 
treatment.  She  recovered  from  the  acute  attack,  but  her  suffering 
at  her  periods  was  far  greater  than  ever  before.  Epileptiform  con- 
vulsions came  with  her  pelvic  pains,  and  were  repeated  frequently 
until  the  menstrual  period  passed  by.  For  several  years  her  time 
was  spent  between  her  home  and  the  hospital,  and  in  occasional 
efforts  to  do  the  duties  of  a  house-servant. 

Condition  when  First  Examined. — Having  obtained  the  above 
history  from  the  patient,  I  observed  that  she  still  had  all  the  evidence 
of  fair  general  health,  except  that,  from  pain  and  the  use  of  mor- 
phine, her  nervous  system  was  decidedly  impaired. 

Physical  Signs. — The  touch  detected  a  very  small  cervix  uteri 
which  projected  into  the  vagina  only  half  an  inch.  The  organs  and 
tissues  were  fixed,  and  on  the  left  side  there  was  an  irregular  mass 
which  felt  like  the  products  of  a  former  pelvic  peritonitis.  On  the 
right  side  the  parts  were  less  elastic  than  normal,  and,  owing  to  an 
exceedingly  tense  state  of  the  abdominal  muscles,  the  body  of  the 
uterus  could  not  be  felt,  neither  could  the  right  ovary  be  positively 
4  .  "  ' 


34  DISEASES  OF  WOMEN. 

made  out.  From  the  negative  signs,  liowever,  I  was  able  to  satisfy 
myself  that  the  right  ovary  was  not  enlarged,  nor  was  the  body  of 
the  uterus  as  large  as  it  ought  to  be.  The  s])eculuiii  revealed  noth- 
ing of  value,  but,  in  using  the  sound  through  it,  1  could  pass  that  in- 
strument into  the  cavity  of  the  uterus.  The  canal  of  the  cervix  was 
an  inch  in  length,  and  in  its  proper  positicjii  as  indicated  by  the 
sound.  When  the  internal  os  was  reached,  the  sound  turned  to  the 
right  and  passed  in  that  direction  about  an  inch.  This  led  me  to 
suspect  that  the  uterus  was  unicornis.  To  obtain  further  evidence, 
the  speculum  was  removed,  while  the  sound  was  left  in  the  uterus. 
The  patient  was  then  placed  upon  the  back,  and,  by  the  rectal  and 
vaginal  touch  combined,  tlie  horn  of  the  uterus  above  the  vagina 
was  reached.  While  making  the  combined  touch,  an  assistant 
rocked  the  horn  of  the  uterus  with  the  sound,  and  I  could  then  out- 
line it  with  the  fingers.  It  was  about  an  inch  in  its  transverse,  and 
only  a  little  more  in  its  long  diametei*.  The  ujjper  end,  which  re])- 
resented  the  fundus,  appeared  to  be  slightly  pointed  in  place  of 
rounded,  as  is  tlie  fundus  of  tlie  normal  uterus. 

Treatment.— T\\Qve  was  nothing  in  the  case  to  give  the  slightest 
hope  that  she  would  derive  benefit  from  any  general  treatment. 
The  removal  of  the  ovaries  to  stop  tlie  tendency  to  menstruation  was 
the  only  indication  apparent  to  my  mind,  and,  owing  to  the  old  adhe- 
sions from  the  former  pelvic  peritonitis,  the  dangers  of  that  opera- 
tion were  fully  appreciated.  The  case  was  explained  to  the  patient 
and  the  friends  who  brought  her  for  my  advice,  and  they  were  left 
to  choose  between  the  removal  of  the  ovaries,  or  no  further  care  on 
my  part.  The  patient,  after  thinking  of  the  dangers  and  the  pros- 
pects, became  very  anxious  for  the  operation.  Her  argument  was 
that  she  was  tired  of  life,  and  that  all  her  friends  were  tired  of  car- 
ing for  her,  and,  if  there  was  one  chance  in  a  thousand  of  being  re- 
lieved, she  longed  for  that  chance. 

The  operation  was  performed  with  great  difficulty,  owing  to  the 
adhesions.  The  right  ovary  was  completely  surrounded  witli  inflam- 
matory products,  and  was  found  with  much  trouble.  The  left  ovary 
was  adherent  at  several  points  that  were  easily  broken  up.  There 
was  no  trace  of  the  left  horn  of  the  uterus,  nor  of  the  left  Fallopian 
tube.  The  right  ovary  was  located  within  one  inch  of  the  u]*])er 
end  of  the  right  horn  of  the  uterus,  and  there  was  no  well-defined 
Fallopian  tube  on  that  side. 

Conimentft. — This  case  certainly  illustrates  fully  the  great  suffer- 
ing that  may  arise  from  this  degree  of  malformation.  The  presence 
of  well-developed  ovaries  which  excite  a  demand  for  menstruation, 


ARREST  OF  dp:vi-:lopment.  35 

associated  with  a  ntenis  incapable  of  [jerforniiiig  that  function,  is 
one  of  the  most  inifortimate  conditions  known  to  the  gynecologist. 
It  is  evident,  also,  that  the  development  of  the  one  horn  of  the  uterus 
sufficient  to  make  a  slight  effort  to  menstruate  only  aggravated  the 
difficulty.  She  would  perhaps  have  been  better  had  the  uterus  l)een 
absent  altogether. 

Incidentally,  I  may  remark  that  the  absence  of  the  tubes  in  this 
case  is  evidence  against  those  who  claim  that  they  have  a  leading 
influence  in  causing  menstruation. 

Rudimentary  Uterus  Bicornis ;  Entire  Absence  of  Menstruation. — 
When  first  examined,  this  lady  was  thirty  years  old,  below  the  aver- 
age size,  but  well  formed,  and  presented,  to  outward  appearances,  all 
the  characteristics  of  her  sex.  As  a  child  she  was  rather  small  and 
delicate,  but  had  good  health.  At  the  age  of  sixteen  she  passed 
through  all  the  changes  of  form  common  to  puberty,  but  never 
menstruated.  When  questioned  regarding  her  health  at  that  time, 
she  remembered  only  that  she  occasionally  had  slight  headache  and 
indisposition,  but  whether  these  symptoms  came  periodically  or  not 
she  did  not  know.  At  no  time  was  her  suffering  sufficient  to  inter- 
rupt her  school  duties.  She  was  married  at  eighteen,  and,  while  she 
was  affectionate  and  devoted  as  a  wife,  sexually  she  was  perfectly 
negative.  Without  being  very  strong  mentally  or  physically,  she 
enjoyed  good  health,  and  only  called  upon  me  at  the  time  she  did 
because  of  some  temporary  irritation  of  the  urethra  which  caused 
pain  on  urination.  This  gave  me  an  opportunity  to  examine  her 
pelvic  organs.  The  external  organs  were  normal,  and  the  vagina 
also.  The  cervix  uteri  was  not  more  than  five  eighths  of  an  inch  in 
diameter.  The  os  externum  was  small  but  normal.  In  the  location 
of  the  body  of  the  uterus  two  small,  oblong,  bifurcated  bodies  were 
found  continuous  with  the  cervix.  These  bodies  were  about  a 
quarter  of  an  inch  thick  and  about  an  inch  long,  as  nearly  as  could 
be  estimated  hy  the  bimanual  examination.  I  regarded  them  as  the 
rudimentary  horns  of  the  uterus,  which  were  retroverted.  Near  the 
upper  ends  of  the  horns  of  the  uterus,  and  a  little  outside  of  them, 
two  other  bodies  were  found  which  I  presumed  to  be  the  ovaries. 
They  were  about  half  the  size  of  a  fully-developed  ovary  and  of  the 
usual  form  of  that  organ,  except  that  they  were  not  so  fiat  from 
before  backward,  and  appeared  to  be  more  dense  than  normal. 
It  was  evident  that  the  development  of  the  ovaries  had  progressed 
further  than  that  of  the  uterus,  because  they  were  relatively  much 
larger  than  the  rudiments  of  the  uterus.  Owing  to  the  fact  that  the 
patient  was  of  small  size,  with  non-resisting  abdominal  muscles  and 


3t)  DISEASES   OF    WOMEN. 

the  ruduueiits  of  the  uterus  retroverteU,  the  examination  was  easy, 
so  that  I  feel  some  confidence  in  giving  the  physical  signs  and  the 
diagnosis  based  upon  them,  believing  that  they  are  correct. 

Comiiunts. — This  case  a])parently  sIkjws  that  the  ovaries  were 
sufficiently  developed  to  influence  the  changes  which  occur  at  pu- 
berty, bat  were  so  much  und^r  size  that  they  were  incapable  of  the 
highest  functional  activity,  while  the  uterus  was  not  only  arrested 
in  its  development,  but  in  its  growth  also  ;  hence  menstruation,  even 
in  an  imperfect  way,  was  impossible.  This  case  is  placed  in  con- 
tnist  with  the  preceding  one  to  show  that  when  arrest  of  develop- 
ment and  growth  is  such  as  to  render  functional  action  entirely 
impossible,  a  fair  degree  of  health  may  still  be  maintained  ;  while, 
on  the  other  hand,  if  the  development  and  growth  of  the  ovaries  are 
complete,  and  the  uterus  is  developed  sufficiently  to  make  an  im- 
perfect effort  to  menstruate,  the  health  and  usefulness  of  such  a 
one  is  greatly  impaired,  and  a  life  of  suffering  generally  follows. 

Small  Uterus  from  Arrested  Growth ;  Scanty  Menstruation  im- 
proved by  Treatment. — The  ])atient  was  a  young  woman  of  full  size 
and  well  formed,  and  of  a  sanguine,  nervous  temperament,  and  a 
remarkably  good  and  well-cultivated  mind.  She  had  always  enjoyed 
good  health  excepting  when  she  was  fourteen  years  old.  At  that 
time  she  was  "  working  hard  at  school,  and  became  run  down." 
Rest  soon  restored  her,  and  she  began  to  menstruate  at  the  age  of 
fourteen  years  and  six  months.  Her  menses  from  that  time  returned 
regularly,  but  the  flow  was  scanty  and  lasted  only  forty-eight  hours. 
During  the  menstrual  period,  and  for  several  days  after  it,  she  suf- 
fered from  fullness  of  the  head,  restless  nights,  and  a  feeling  of 
discomfort  in  the  pelvis  with  general  mental  and  physical  indispo- 
sition. She  continued  in  this  way  until  she  was  mature,  the  time 
when  she  was  first  examined.  By  the  touch  the  cervix  uteri  was 
found  to  be  rather  small,  but  well  formed  and  in  proper  relations  to 
the  vagina.  Owino;  to  the  rigid  state  of  the  abdominal  muscles,  the 
uterus  c(nild  not  be  satisfactorily  outlined  by  the  bimanual  touch. 
Using  the  sound  through  the  speculum,  the  long  diameter  of  the 
uterus  was  proved  to  be  one  and  seven  eighths  inches  ;  (juite  a  small 
uterus  for  a  woman  of  her  size.  Her  general  health  was  very  good 
indeed,  and  she  would  not  have  sought  innnediate  advice  had  it  not 
been  that  she  was  engaged  to  be  married,  and  was  very  anxious  to  be 
relieved  from  the  ill  feelings  which  came  in  connection  with  her 
scanty  menstruation. 

Treatment. — At  her  next  pei-iod  she  was  directed  to  take  a  tea- 
spoonful  every  three  hours  of  the  following  mixture  :  Amnion,  niur., 


ARREST   OF   DEVELOPMENT.  37 

3  ij  ;  aqnjie  campli,,  5  ^■,  to  Ije^in  as  soon  as  she  felt  that  the  period 
was  approaching,  and  to  continue  until  six  hours  after  the  flow 
stopped.  Not  beinw  used  to  medicine,  she  objected  to  it  strongly, 
and  during  her  subsequent  periods  she  took  a  teaspoonful  of  Hq. 
ammon.  acetatis  every  three  hours,  commencing  one  day  before  the 
flow  began  and  during  its  continuance.  Immediately  after  the  flow 
ceased,  one  or  more  line  punctures  were  made  near  the  external  os, 
which  piroduced  considerable  bleeding.  This  was  done  to  relieve, 
as  far  as  possible,  the  congestion  which  lingered  because  it  was  not 
relieved  by  the  menstrual  flow.  This  was  practiced  after  three  pe- 
riods. At  intervals  of  six  days  during  the  entire  menstrual  flow  the 
canal  of  the  cervix,  including  the  internal  os,  was  gently  dilated 
with  graduated  sounds.  This  was  done  in  the  hope  that  it  would 
stimulate  the  nutrition  of  the  uterus. 

After  the  third  month  of  treatment  it  was  found  that  the  men- 
strual flow  had  increased  in  quantity  and  continued  for  one  day 
longer.  A  stem-pessary  was  then  introduced,  but  it  caused  more 
irritation  than  was  safe ;  so,  after  it  had  been  worn  for  three  days, 
it  was  removed,  and  not  used  again. 

From  this  time  onward  the  treatment  was  limited  to  a  mild  con- 
stant electric  current.  One  electi'ode  was  passed  into  the  uterus,  the 
other  applied  alternately  over  the  sacrum  and  supra-pubic  region. 
This  was  repeated  every  six  days  in  the  interval  between  the  monthly 
periods.  She  continued  to  take  the  solution  of  acetate  of  ammoniii 
at  each  period,  but  with  what  benetit  is  not  known.  At  the  end  of 
eight  months  the  uterus  measured  two  inches  and  one  eighth  in  its 
long  diameter,  and  she  menstruated  between  four  and  Ave  days  at 
each  time,  the  flow  being  much  more  free  and  her  unpleasant  symp- 
toms having  all  disappeared.  She  was  married  then,  and  I  lost  sight 
of  her  for  seven  months,  when  she  called  to  consult  me  regarding 
amenorrhoea,  which  had  existed  for  two  months  and  was  due  to 
pregnancy.  I  heard  that  subsequently  she  was  conflned,  and  was  in 
quite  good  health. 

Undersized  Uterus  from  Arrested  Growth ;  Scanty  Menstruation ; 
Sterility ;  Incurable. — This  woman  was  thirty  years  old  when  this 
history  was  obtained.  She  was  of  medium  size,  and  had  enjoyed  fair 
health  most  of  her  life.  During  her  girlhood  she  had  to  work  very 
hard  in  a  store,  and  often  suffered  at  that  time  from  fatigue.  She 
developed  slowly,  and  did  not  menstruate  until  seventeen  years  of 
age.  During  the  flrst  four  years  after  puberty  the  menses  lasted 
only  two  days  and  the  flow  was  scanty.  At  twenty-two  she  was 
married,  and  placed  in  easier  and  more  comfortable  cu'cumstauces, 


38  DISEASES   OF   WOMEN. 

and  for  about  one  year  tlic  menstrual  flow  lasted  fnjni  two  and  one 
lialf  to  tliree  days  at  each  time.  She  then  mibsed  one  jjeriod,  and 
then  the  menses  returned  more  freely  than  ever  before,  which  made 
her  believe  she  had  had  a  miscarriage ;  but  of  this  there  was  no 
proof.  AVhen  she  had  been  married  two  yeai*8  she  began  to  have 
pain  of  a  tlull,  aching  character  in  the  region  of  the  uterus  during 
her  menses.  This  pain  became  more  marked  as  time  advanced,  and 
gradually  the  pain  extended  to  the  ovaries.  These  pains  were  never 
acute,  and  passed  away  entirely  after  menstruation  ceased.  At 
twenty-nine  years  of  age  she  had  sickness  in  her  family  and  was 
overtaxed  thereby,  and  her  menses  stopped  for  Ave  months,  but 
again  returned.  In  the  absence  of  the  menses  she  had  leucorrh(jL'a, 
but  not  before  nor  since. 

Examination  by  the  touch  showed  the  uterus  to  be  relatively 
long  and  narrow ;  the  body  was  not  much  larger  than  the  cervix. 
The  long  diameter  as  measured  with  the  sound  was  two  inches. 
There  was  slight  tenderness  on  pressure  over  the  ovaries.  AH  the 
pelvic  organs  were  in  normal  position.  Her  general  health  was 
about  as  good  as  it  ever  had  been. 

Treatment. — Sodium  bromide,  gr.  xxx,  was  given  three  times  a 
day  in  Vichy  water  before  meals  during  the  menstrual  period.  This 
relieved  the  uterine  and  ovarian  pain  very  much.  Between  the 
periods  the  hot-water  douche  was  used  until  all  pain  had  been  relieved. 
The  subsequent  ti'eatment  Avas  about  the  same  as  in  the  case  last 
related,  with  the  addition  of  more  extensive  dilatation  of  the  cervical 
canal,  and  she  also  wore  the  intrauterine  stem-pessary  for  six  weeks. 
She  also  took  interaally  phosphates,  iron,  and  strychnia  in  various 
forms,  and  for  several  mouths. 

At  the  end  of  seven  months  she  was  free  from  all  pain  during 
menstruation,  but  the  flow  was  no  freer,  nor  did  it  last  any  longer. 
The  uterus  had  not  in  the  least  increased  in  size.  She  was  dis- 
missed unimproved,  so  far  as  the  growth  of  the  uterus  was  con- 
cerned. 

Comments. — This  and  the  preceding  case  are  placed  together  to 
show  the  i-esults  of  treatment.  They  demonstrate  that  the  prospects 
of  success  in  increasing  the  growth  of  the  uterus  depend  very  largely 
upon  the  age  of  the  patient.  The  earlier  in  life  that  the  treatment 
is  begun,  the  more  likelihood  is  there  of  success. 

Undersized  Uterus,  its  Growth  apparently  being  arrested  by  Pre- 
mature Sexual  Nervous  Excitation ;  Irregular  and  Painful  Menstruation ; 
all  the  Symptoms  increased  by  Local  Treatment. — This  was  a  single 
woman,  twenty-two  years  old,  the  daughter  of  wealthy  and  educated 


ARREST   OF   DEVELOPMENT.  39 

parents.  She  was  tall,  spare,  and  of  nervous  temperament.  Before 
puberty  she  acquired  the  habit  of  self-abuse  while  at  school.  While 
her  general  system  was  not  developed,  and  while  weak,  irritable,  dys- 
peptic, and  subject  to  severe  headaches  she  began  to  give  evidences 
of  puberty,  and  her  menses  iirst  appeared  at  twelve  years  of  age. 
From  this  time,  up  to  the  time  of  taking  this  history,  she  menstruated 
irregularly,  the  average  time  between  the  periods  being  five  weeks, 
but  often  two,  three,  and  on  several  occasions  five  months  elapsed. 
The  flow  was  usually  normal  in  (juantity,  character,  and  duration, 
although  the  latter  was  variable.  Pain  in  the  back,  pelvis,  and  lower 
portion  of  the  abdomen  always  accompanied  the  menses,  and  was  suf- 
ficiently severe  to  keep  her  in  bed  during  that  period.  The  severity 
of  the  pain  was  presumably  not  so  great  as  the  patient  described. 
Her  extreme  sensitiveness  inclined  her  to  exaggerate  her  sufferings. 
Neither  was  the  character  of  the  pain  so  acute  and  localized  as  that 
which  occurs  in  flexion  of  the  uterus.  Her  general  health  was  poor, 
slight  mental  or  pliysical  exercise  fatigued  her,  and  if  she  persisted 
she  became  so  tired  that  she  could  not  rest.  Her  sleep  was  disturbed 
by  dreams  that  were  not  all  dreams,  and  in  the  morning  she  felt 
quite  exhausted.  Before  I  saw  her  she  had  been  treated  locally 
and  generally  by  several  physicians,  some  of  high  standing  in  the 
profession,  and  others  of  questionable  repute,  and  was  invariably 
worse  after  being  treated. 

An  examination  by  touch  i*evealed  a  small  uterus  slightly  retro- 
verted,  though  that  malposition  was,  I  believe,  temporary.  The 
length  of  the  uterine  cavity  measured  with  the  sound  was  a  fraction 
less  than  two  inches.  With  the  exception  of  extreme  sensitiveness 
of  the  pelvic  organs  generally,  there  was  no  other  abnormality 
found. 

Local  treatment  was  tried  for  a  short  time,  but  it  was  found  to 
be  injurious.  She  was  then  given  systematic  occupation  under  the 
direction  of  a  skilled  attendant.  Massage  and  careful  dieting  were 
also  dii'ected.  Her  days  were  fully  occupied  with  short  alternating 
periods  of  mental  and  phj'sical  exercise  and  rest.  Ever}^  afternoon 
she  took  thirty  grains  of  bromide  of  sodium,  and  dm'ing  her  men- 
strual periods  thirty  grains  three  times  a  day  with  eight  drops  of 
tincture  of  cannabis  Indica.  Laxatives  were  given  to  regulate  the 
bowels,  and  tonics  occasionally  when  specially  required.  It  should 
be  mentioned  that  she  gave  up  her  evil  habit  as  soon  as  she  was  made 
to  understand  its  ill  effects.  Under  this  general  plan  of  treat- 
ment she  improved  in  every  respect.  She  still  suffers  at  her  monthly 
periods,  and  the  raenstraal  function  is  still  irregular. 


40  DISEASES   OF    WOMEN. 

Conunenta. — This  case  is  given  as  a  representative  of  that  class  of 
cases  of  delayed  or  arrested  growth  of  the  uterus  uihI  the  functional 
imperfection  wliicli  is  sure  to  follow,  the  primary  cause  of  all  being 
the  premature  excitation  of  the  sexual  organs.  A  sufficient  number 
of  these  cases  h-is  been  seen  and  studied  to  warrant  the  statement 
that  when  the  habit  of  self-abuse  is  begun  befitn-  puberty  it  often 
arrests  the  develo])ment  or  growth,  or  both,  of  the  uterus,  and  the 
consequences  are  far  more  disastrous  than  the  same  practice  when 
begun  after  puberty  and  com])leted  growth. 

C/lo.sely  associated  with  this  subject  is  chlorosis,  a  condition  in- 
volving menstrual  derangements  due  to  the  same  defect  of  the 
uterus,  being  associated  with  lesions  of  the  general  system.  Chloro- 
sis is  a  condition  which  has  usually  been  considered  as  a  disease  pet' 
se,  but  it  appears  to  me  to  be  rather  a  peculiai'  character  of  organiza- 
tion presenting  invariably  certain  characteristics  of  structuie  which 
are  unfavorable  to  high  functional  activity,  and  which  predispose  to 
certain  forms  of  disease.  Some  authorities,  French  mostly,  believe 
that  chlorosis  is  a  disease  of  the  organic  nervous  system  which 
appears  at  puberty  and  presents  certain  changes  of  nutrition,  espe- 
cially in  the  character  of  the  blood.  There  is  certainly  some  reason 
for  this  view  of  the  subject.  The  functions  of  the  body  which  are 
under  the  direct  control  of  the  organic  nerve-centers  are  perverted 
apparently  by  some  obscure  derangement  of  organic  innervation,  ])ut 
this  appears  to  come  from  some  imperfection  of  the  nervous  system, 
perhaps  mal-development,  i-ather  than  from  some  well-defined  dis- 
ease. The  German  pathologists  hold  that  in  chlorosis  there  is  an 
arrest  of  growth  of  the  circulatory  and  genital  systems;  the  heart 
and  blood-vessels  beins;  undersized  and  the  sexual  organs  also. 
This  certainly  corresponds  to  the  facts  as  observed  clinically,  and  if 
to  this  be  added  that  jiecuHar  condition  of  the  organic  nervous  sys- 
tem, which  is  undefined  but  ])robably  structural,  a  type  of  organiza- 
tion results  which  presents  all  the  tangible  characteristics  of  chlorosis. 
This  is  the  conce))tion  which  I  have  accepted  regarding  chlor(»sis, 
which  may  be  defined  as  an  organization  in  which  the  circulatory 
and  the  genital  systems  are  below  the  normal  type  in  point  of  devel- 
opment and  growth,  and  in  which  there  is  a  state  of  the  organic 
nervous  system  which  is  also  bel<»w  the  normal  and  incapable  of  exer- 
cising the  highest  functional  activity.  These  constitutional  conditions 
combine  the  features  of  a  peculiar  temperament  and  a  diathesis; 
the  temperament  being  so  marked  as  to  show  a  tendency  to  disease 
or  diathesis.  It  would  simplify  the  subject  if  the  term  chlorotic 
temperament   were   used   to   express   this   constitutional  condition. 


ARREST  OF  DEVELOPMENT.  41 

Viewing  the  subject  from  this  standpoint,  it  is  easy  to  understand 
that  such  an  ori^anization,  wliile  it  uiight  act  under  the  most  favor- 
able circumstances  of  life,  would  be  incapable  of  sustaining  the' 
more  complex  functional  activities  of  a  mature  and  fully  occupied 
life.  It  is  easy  to  see,  also,  that  a  chlorotic  subject,  when  called 
upon  to  take  up  the  functions  of  reproduction,  when  thus  ill-quali- 
fied to  do  so  by  reason  of  anatomical  defects,  would  naturally  tend 
to  derangements  of  nutrition  in  the  form  of  impaired  appetite, 
labored  digestion,  and  the  anojmia,  debility,  and  mental  depression 
which  naturally  follow  mal-nutrition.  So,  also,  would  the  sexual  sys- 
tem suffer  because  of  the  undersize  of  the  uterus  and,  presumably  in 
some  cases,  the  ovaries  also,  together  with  the  imperfect  blood- 
supply  which,  sooner  or  later,  comes  from  the  mal-nutrition.  This, 
I  believe,  to  be  the  true  state  of  the  body  known  as  chlorosis,  nnd 
that  all  the  phenomena  manifested  by  such  subjects  are  the  outcome 
of  their  anatomical  peculiarities.  Whether  this  be  the  proper  de- 
scription of  chlorosis  or  not,  it  is  the  expression  in  brief  of  the 
prominent  features  of  chlorotic  subjects,  and  agrees  with  the  facts 
observed  in  practice.  The  reason,  I  presume,  for  the  different  opin- 
ions held  has  grown  out  of  the  fact  that  some  have  accepted  the 
mal-nutrition  which  is  so  often  seen  in  the  chlorotic,  and  the  conse- 
quences thereof,  as  the  disease  itself ;  whereas  these  derangements 
of  the  nutritive  and  sexual  systems  are  the  outcome  of  the  anatom- 
ical imperfections.  The  chief  object  in  discussing  the  subject  here 
is,  because  chlorotic  women  necessarily  suffer  from  deranged  and  im- 
perfect menstruation,  and  they  naturally  fall  into  the  care  of  the 
gynecologist,  and  without  some  definite  idea  of  the  nature  of  this 
affection  its  rational  management  would  not  be  possible. 

From  the  very  nature  of  chlorosis,  it  is  clearly  evident  that  the 
object  of  the  therapeutist  should  be  to  aid  in  the  development  and 
growth  of  the  subject  while  young,  in  the  hope  of  overcoming  the 
natural  tendencies  to  these  constitutional  defects.  After  adolescence 
the  most  that  the  physician  can  accomplish  is  to  overcome,  as  far  as 
can  be,  the  mal-nutrition  and  derangements  of  menstruation,  which 
arise  from  the  constitutional  imperfections. 

Arrested  Growth  of  the  Uterus,  associated  with  Small  Circulatory 
Organs ;  Chlorosis. — This  patient  stated  that  when  a  girl  she  was  of 
medium  size  and  quite  fleshy,  and  was  said  by  her  friends  to  look 
strong  and  healthy,  but  she  was  never  able  to  endure  much  muscu- 
lar exercise.  Her  appetite  and  primary  digestion  had  generally  been 
good,  yet  she  never  required  a  large  quantity  of  food.  Her  face 
was  rather  pale  while  a  girl,  and  ]-eniained  so.     She  never  was  in- 


42  DISEASES  OF   WOMEN. 

clined  to  take  active  exercise,  and,  when  obliged  to  do  so,  respira- 
tion was  labored,  and  she  soon  became  tired. 

At  the  age  of  lifteen  she  began  to  show  the  general  form  of 
womanhood,  but  did  not  menstruate  until  eight  months  later.  From 
that  tin)e  onward  she  menstruated  regularly,  but  the  flow  lasted  only 
three  days,  and  was  not  at  all  free.  On  several  occasions,  when 
obliged  to  exert  herself  sufticiently  to  slightly  lower  her  geuerid 
health,  the  menstrual  flow  was  almost  colorless,  and  lasted  only  two 
days.  At  twenty-one  she  was  married.  Her  general  health  remained 
as  before,  and  she  proved  to  be  stei-ile.  1  saw  her  when  she  was 
twenty- eight  years  of  age,  seven  years  after  being  mamed.  She  then 
consulted  me  regarding  her  sterility. 

In  general  appearance  she  was  a  typical  chlorotic  subject.  She 
was  of  medium  height,  quite  fleshy,  but  not  inordinately  so;  her 
hair  was  intermediate  in  color,  being  neither  dark  nor  light — in 
fact,  it  might  be  said  to  Ije  colorless ;  too  light  for  a  bninette,  too 
dark  for  a  blonde.  If  this  dark  shade  had  been  removed,  it  would 
have  been  hair  of  a  dark-flaxen  color;  the  eyes  were  a  gray-blue  and 
very  clear;  the  sclerotic  coat  pearly  white;  the  skin  remarkably 
smooth  and  white.  The  face  was  pale,  with  that  greenish-yellow 
hue  which  must  be  seen  to  be  fully  a]jpreciated.  This  color  of  the 
face  differs  from  the  yellow,  dry  skin  of  the  cachectic  subject,  the 
pallor  of  ansemia,  and  the  bronze  of  sunburn.  Few  blood-vessels 
were  visible  on  the  face  or  hands,  and  these  were  very  small.  The 
pulse  was  about  eighty,  but  small,  more  like  that  of  a  child.  The 
heart-sounds  were  very  clear  and  distinct,  but  the  impulse  was  weak. 
The  area  of  cardiac  dullness  was  ap])ar«ntly  smaller  than  usual,  l)ut 
this  was  difficult  to  make  out,  owing  to  the  mammary  glands  l)eing 
large.  At  the  time  of  my  flrst  examination  she  was  feeling  more 
than  usually  languid  and  weak  because  of  indigestion  and  constipa- 
tion, which  had  troubled  her  for  several  weeks.  Her  tongue  was 
coated,  and  her  appetite  poor.  On  walking  upstairs  quickly  she 
suffered  from  "  want  of  l)reatli."  If  she  stooj)ed  down  and  rose 
suddenly,  she  had  vertigo.  Toward  night  her  ankles  became 
slightly  swollen.  Her  sleep  was  often  disturbed  by  dreams.  In  dis- 
position she  was  a  little  sluggish,  good-natured,  and  generally  cheer- 
ful, with  occasional  attacks  of  mental  dejiression,  which  occurred 
usually  at  the  menstrual  period. 

The  pelvic  organs  were  normal  as  regards  general  nutrition,  except 
that  the  mucous  membrane  was  anaemic.  The  position  of  the  uterus 
was  normal.  The  sound  showed  the  cavity  of  the  uterus  to  be  a 
fraction  under  two  inches  in  length.     There  was  a  slight  leucor- 


ARREST   OF   DEVELOPMENT.  43 

rli(va.  The  menses  were  regular,  lasting  from  three  to  four  days, 
until  four  months  before  she  was  Urst  seen  by  me.  During  that 
timo  slic  had  had  a  leucorrlioaal  discharge  at  tlie  menstrual  period, 
hut  nothing  more. 

Treatment. — Pil.  liydrarg.,  gr.  x;  pulv.  ipecac.,  gr.  j,  were  given 
at  bedtime,  and  a  saline  laxative.  After  this,  a  teaspoonful  of  the 
following  mixture  was  given,  well  diluted,  before  meals  :  Strychnise 
sulphatis,  gr.  ss ;  auid.  hydrochlor.,  3  j ;  tinct.  cardam.  conip.,  ^  j  ; 
aqute  font.,  5  ij.  This  improved  her  appetite,  and  her  strength  in- 
creased. When  she  had  hnished  the  first  mixture,  the  following  was 
given:  Ferri  iodid.,  3j;  quiniee  sulph.,  gr.  x;  ext.  belladonnse,  gr. 
ij,  in  pil.  Ko.  XX,  one  before  each  meal.  These  pills  were  taken 
with  apparent  benefit  for  three  weeks,  when  they  were  stopped,  and 
the  following  was  ordered  :  Tinct.  iodin.,  3  ij  ;  potass,  iodidi.,  3  ss  ; 
syr.  simp.,  3  j ;  aquse  font.,  ^  ij  ;  one  teaspoonful,  after  meals,  in 
water.  During  the  following  six  weeks  she  took  the  pills  one  week, 
and  the  next  week  the  tincture  of  iodine  mixture,  alternating  regu- 
larly. The  menses  appeared  at  the  fifth  month  after  they  stopped, 
but  were  scanty,  and  lasted  only  two  days.  The  aj)petite  and  diges- 
tion were  improved,  and  the  anaemia  was  less  marked.  She  also 
felt  much  stronger.  1  then  prescribed  ferri  pyrophos.,  3  jss ;  strych- 
nise  sulph.,  gr.  ss;  liq.  potass,  arsenit.,  3j;  tr.  colomb.,  ^j;  aquae 
font.,  3ij.  Teaspoonful,  in  water,  after  meals.  This  mixture  she 
continued  to  take  for  six  weeks  longer,  omitting  it  occasionally  for 
a  few  days.  During  the  treatment  she  was  relieved,  as  far  as  pos- 
sible, from  all  care,  took  light  exercise  in  the  open  air,  and  had  a 
good  supply  of  nutritious  food  in  great  variety,  being  restricted  only 
in  the  quantity  of  fiuids,  sugar,  and  fats  that  she  took.  The  menses 
continued  from  this  time  onward  to  be  regular,  and  the  character 
and  duration  of  the  flow  were  the  same  as  they  had  been  in  her  best 
former  health,  but  were  not  improved.  For  several  years,  indeed  up 
to  the  present  time,  which  is  now  five  years  since  she  was  first  seen, 
she  has  been  in  fair  health,  but  on  several  occasions,  when  she  ven- 
tured to  do  more  than  usual,  her  digestion  became  deranged  and 
her  appetite  poor.  Anaemia  has  become  more  marked,  and  the 
menses  have  diminished,  but  she  has  ]3romptly  applied  for  ti"eatment, 
and  the  use  of  tonics  has  restored  her  to  her  usual  rather  low  stand- 
ard of  health. 

Co?)iments. — This  history  shows  that  the  patient  was  not  cui-ed 
of  her  chlorosis,  but  only  reheved  from  intercurrent  attacks  of  mal- 
mitrition  and  the  consequent  imj^erfect  menstruation  which  she  had. 

This  is  the  history  of  the  great  majority  of  such  cases  when  they 


44  DISEASES  OF    WOMEN. 

come  under  observation  and  treatment  aftL-r  })\il)erty.  This  shows 
that  the  whole  character  of  the  organization  is  below  the  highest 
standard,  and  hence  there  is  a  tendency  to  break  down  nnder  ordi- 
nary taxiitittn,  and  the  physician  can  do  no  mow  than  restore  tJic 
patient  to  her  usual  degree  of  health. 

Chlorosis  treated  before  Puberty,  with  apparently  Good  Results. — 
A  school-girl,  fourteen  years  old,  lui-ge  enough  for  lier  age,  and  un- 
usually fleshy,  was  brought  to  me  on  account  of  loss  of  appetite  and 
constipation  There  was  no  evidence  of  puberty,  except  that  her 
breasts  were  large,  but  they  were  mostly  made  up  of  adipose  tissue. 
Her  general  appearance,  color  of  hair  and  eyes,  small  heart  and 
blood-v^essels,  white  skin,  pale  face,  and  disinclination  to  active  exer- 
cise, indicated  chlorosis.  Nothing  was  lacking  but  the  usual  anivraia 
and  peculiar  color  of  the  face  to  make  the  case  a  type  of  chlorosis. 
She  was  directed  to  give  up  some  of  her  school  duties  and  devote 
more  time  to  systematic  muscular  exercise  and  out-of-door  life,  to 
abstain  from  fat  meat,  sugar,  and  butter,  of  all  of  which  she  was  un- 
usually fond,  and  to  live  upon  lean  animal  food,  fish,  eggs,  oatmeal, 
fruit,  and  brown  bread.  To  relieve  her  coustijDation  I  prescribed 
quin.  sulph.,  3j  ;  ext.  belladonnae,  gr.  ij  ;  ext.  colocynth.  comp.,  gr. 
X,  in  pil.  No.  xx;  one  immediately  before  each  meal.  At  the 
end  of  two  weeks  the  bowels  w^ere  acting  too  freely.  One  pill,  night 
and  morning,  before  meals,  was  ordered.  These  answered  for  a 
time,  but  in  three  weeks  it  was  found  that  one  pill  was  all  that  was 
required,  and  at  the  end  of  two  months  from  the  time  she  came 
under  treatment,  pills  were  given  up  altogether.  She  was  then  put 
upon  the  following : 

^      Hydrarg.  chloridi  corrosivi ^r-  j- 

Liquor  arsenici  chloridi f  3  j- 

Tr.  ferri  chloridi. 

Acid,  hydrochloric,  diluti fia  f  3  iv. 

Syrupi  simplicis ^  ij. 

Aquae q.  s.  ad    3  vj. 

M.  Sig.  :  A  dessertspoonful,  well  diluted,  after  each  meal. 
This  is  known  as  the  mixture  of  the  four  chlorides,  and  is  said 
to  have  been  first  used  by  Tilt,  of  London,  and  was  introduced  to 
the  profession  of  Philadelphia  by  the  late  Dr.  A.  II.  Smith.  This 
medicine  was  given  for  one  month,  then  omitted  for  two  weeks,  and 
again  taken  for  one  month.  After  this,  she  was  given  iodide  of 
iron  in  small  doses  for  two  months.  In  summer  she  was  sent  to  the 
mountains,  and  encouraged  to  ramble  in  the  open  air,  to  drive,  and 
occasionally    ride    on    horseback.      The  diet  that  was  first  recom- 


ARREST   OF   DEVELOPMENT.  45 

mended  was  continued,  except  that  she  occasionally  indulged  her 
fancy  for  sweets. 

Under  this  course  of  treatment  she  lost  Hesh,  and  grew  taller  and 
stronger.  Her  pulse  was  markedly  improved,  and  her  appetite  con- 
tinued to  be  very  good.  At  the  age  of  fifteen  years  and  three 
months  she  showed  evidences  of  maturity,  and  simultaneously  her 
appetite  became  somewhat  capricious ;  backache  and  headache  occa- 
sionally troubled  her,  and  she  was  at  times  depressed.  The  mixture 
of  the  chlorides  was  resumed  and  continued  for  one  month.  Her 
usual  order  of  life  was  continued,  except  that  she  did  not  ride  on 
horseback,  and  was  carefully  guarded  from  overtaxation,  mental 
and  physical.  The  menses  appeared  and  continued  for  four  days 
normally,  and  were  not  attended  with  great  pain.  In  six  weeks  the 
flow  returned,  and  lasted  the  same  length  of  time.  From  this  on- 
ward for  one  year  the  menses  were  normal.  After  that,  she  went 
to  a  higher  school,  and  tried  to  make  up  for  lost  time  in  her  studies. 
During  this  time  she  was  not  seen,  i.  e.,  for  about  one  year  and  four 
months.  Then  she  called  upon  me,  and  the  following  history  was 
obtained  :  Her  appetite  was  capricious,  and  her  bowels  constipated  ; 
she  had  headache  often ;  slept  in  a  restless,  dreamy  way ;  had  pain 
in  the  prtecordial  region  and  dorsal  portion  of  the  spine ;  was  easily 
frightened,  and  had  palpitation  of  the  heart  on  taking  exercise. 
The  menses  w^ere  delayed  for  two  weeks,  and  when  they  returned  the 
flow  was  scanty,  and  lasted  only  three  days.  At  this  time  she  had  a 
more  marked  chlorotic  appearance  of  the  face  than  at  any  time 
before.  The  pills  previously  prescribed  were  given  to  keep  the 
bowels  regular,  and  the  mixture  of  chlorides  was  given  for  one 
month,  and  after  that  she  was  given  twenty  minims  of  the  sirup  of 
the  iodide  of  iron  three  times  a  day.  The  thought  of  falling  behind 
in  her  studies  grieved  her  so  much,  that  she  was  placed  under  the 
care  of  a  governess,  who  interested  her  in  her  studies  but  did  not 
harass  her. 

The  menses  became  normal  again,  and  she  regained  her  general 
health,  and  has  since  continued  well.  She  is  at  this  time  married, 
and  the  mother  of  one  child. 

Comments. — It  is  not  possible  to  prove  that  this  patient  would 
have  become  a  well-defined  chlorotic  subject,  but  I  am  disposed  to 
believe  that  she  would,  had  she  been  neglected,  as  most  of  these  cases 
are.  In  my  clinical  record  I  find  several  cases  of  this  kind,  and  most 
of  them  have  been  greatly  aided  by  care  and  medication  similar  to 
that  used  in  the  management  of  this  case.  The  benefit  of  treatment 
has  been  most  marked  in  those  who  came  under  care  early  in  life. 


40  DISEASES   OF    WOMEN. 

Tliose  who  had  no  trcutiiieiit  until  after  puberty,  and  were  puffering 
from  all  the  syiiiptoms  of  typical  cases  were  improved  by  treatment, 
so  far  ius  obtainiufj^  relief  from  deran<^e(l  diiresti'tu  and  neuralgia,  and 
to  some  extent  from  anjemia,  but  they  still  maintained  their  consti- 
tutional ])eculiaritie8,  with  a  tendency  to  recurrence  of  the  ana*mia 
and  menstrual  deranirements. 

In  those  who  married  early  and  bore  children  (a  not  unusual 
thing  for  those  in  whom  chlorosis  is  not  marked),  there  was  a  )iotice- 
able  pretlisposition  to  albuminuria  and  ])nerj)eral  convulsions.  Such 
cases  also  tend  to  inertia  of  the  nterus  and  ))0st-partum  liienujrrhage. 
They  very  generally  suffer  from  anaemia  and  nervous  exhaustion  dur- 
ing lactation. 

A  Marked  Case  of  Chlorosis,  complicated  with  Gastric  Derange- 
ment.— The  patient  was  a  domestic,  twenty-three  years  of  age,  and 
presented  all  the  charactei-istics  of  chlorosis  in  a  typical  degree. 

She  had  suffered  repeatedly  from  amenorrlioea,  but  had  always 
responded  to  tonics  sufficiently  to  resume  her  duties  in  a  few  weeks. 

She  was  attacked  with  vomiting,  her  strength  failed  rapidly, 
and  she  was  unable  to  leave  her  room  for  weeks.  When  she  took 
food  it  gave  her  distress,  until  it  was  rejected.  Sometimes  food 
would  be  vomited  after  having  l)een  retained  in  the  stomach  nearly 
an  hour,  but  it  was  not  in  any  degree  digested. 

Gastric  ulcer  was  suspected,  although  she  had  never  vomited 
blood.  She  was  given  peptonized  milk  as  the  onl}-  food.  This  she 
retained  in  increasing  quantity,  and  gradually  regained  her  usual 
health. 

Comments. — This  case  shows  the  strong  characteristics  of  extreme 
anaemia  in  chlorotic  patients.  I  believe  that  the  stomach  is  unable 
to  digest  food  because  of  the  anaemia,  and  this  causes  the  vomiting. 
In  such  cases  the  peptonized  food  is  of  tlie  greatest  ]')ossible  value. 

Menstrual  Derangements  from  Causes  independent  of  the  Sexual 
Organs. — This  class  of  menstrual  disorders  is  closely  related,  in  the 
matter  of  diagnosis,  to  those  deranged  functions  of  the  uterus  due  to 
anatonn'cal  lesions;  hence  the  subject  may  aju-opriately  be  dis- 
cussed here.  It  is  only  necessary  to  call  to  mind  all  the  condi- 
tions necessary  to  menstruation  to  see  plaiidy  that  constitutional 
diseases,  acute  and  chronic,  as  well  as  functional  disturbances  of 
the  nervous  system,  would  act  unfavorably  upon  the  functions 
of  tlie  genital  system.  As  a  general  nile,  any  constitutional  affec- 
tion which  impairs  nutrition  and  I'educes  strength  very  decidedly 
will  affect  menstruation.  This  is  certainly  the  case  when  the  gen- 
eral depression  continues  for  any  great  length  of  time.     The  best 


ARtlEST   OF   DEVELOPMENT.  47 

example  of  this  is  seen  in  phthisis  pnlmonahs.  Tn  tlic  advanced 
stages  of  this  disease  the  menses  usually  stop  altogether.  The 
uterine  function  ceases  under  these  circumstances,  simply  because 
the  general  system  is  unable  to  sustain  it.  In  acute  diseases,  such  as 
pneumonia  or  typhoid  fever,  menstruation  may  be  interrupted  for  a 
period  or  two,  but  it  usually  reappears  when  the  patient  fully  re- 
covers from  the  constitutional  disease.  On  the  other  hand,  in  degen- 
erative diseases,  such  as  organic  diseases  of  the  liver,  lungs,  heart,  or 
kidneys,  the  menses  often  become  irregular  and  scanty  or  profuse, 
and  finally  stop  altogether  during  the  remainder  of  the  invalid's 
life.  So,  also,  severe  shocks  or  over-taxation  from  shock,  exposure 
to  cold,  fear,  grief,  and  extreme  mental  work,  may  cause  the  menses 
to  temporarily  cease.  Again,  either  of  the  constitutional  conditions 
referred  to  above  may  retard  the  first  appearance  of  the  menses  if 
they  are  active  at  the  period  of  puberty,  even  though  the  develop- 
ment and  growth  of  the  genital  organs  may  not  be  arrested. 

Amenorrhoea,  or  delay  of  the  advent  of  the  menstrual  function,  is 
the  rule  when  these  causes  exist.  There  are  exceptions  to  this  rule, 
as,  for  example,  valvular  lesions  of  the  heart  and  cirrhosis  of  the 
liver,  may  cause  menorrhagia,  and  nervous  derangements  may  cause 
premature  menstruation. 

The  diagnosis  in  such  cases  is  usually  easy.  By  the  time  that  the 
uterine  function  becomes  deranged,  the  constitutional  disease  is  so 
far  advanced  as  to  be  easily  recognized.  One  is  greatly  aided  in 
diagnosis  when  the  menses  have  for  a  time  been  regular,  but  become 
deranged  without  any  disease  of  the  sexual  organs  being  present. 

When  amenorrhoea  occurs  as  the  result  of  some  constitutional 
disease  that  is  incurable,  the  special  interest  of  the  gynecologist  ends 
when  the  diagnosis  is  made,  because  no  special  treatment  is  of  any 
avail.  On  the  other  hand,  in  menorrhagia,  when  due  to  chronic 
affections  of  the  heart,  liver,  or  kidneys,  something  may  be  accom- 
plished in  the  way  of  modifying  the  trouble,  and  thereby  prolonging 
the  life  of  the  patient.  Here  also  the  management  is  general,  not 
special,  and  hence  does  not  come  within  the  scope  of  the  present 
work. 

Premature  Menstruation  from  Deranged  Conditions  of  Life  and 
Deranged  Innervation. — The  rule  that  the  menses  should  appear  after 
the  completion  of  development  which  occurs  at  puberty  is  violated  in 
the  cases  now  under  discussion,  because  the  uterine  function  is  taken 
up  before  the  general  development  is  completed.  In  determining 
the  question  of  premature  menstruation  it  is  necessary  to  ascertain 
whether  the  patient  is  sufficiently  mature  in  development  to  render 


48  DISEASES  OF  WOMEN. 

her  capable  of  tiiking  up  this  uterine  function.  Slie  may  be  old 
enough,  but  not  developed  enough  in  her  general  system.  The 
causes  of  this  too  early  a])pearance  of  the  menses  are  various.  It 
seems  that  op[)ositc  conditicms  of  life  produce  the  same  results.  Bad 
air,  poor  food,  overwork,  and  impure  social  surroundings,  have  this 
ill  effect ;  at  least,  cases  frequently  occur  among  those  who  are  so 
poor  that  they  fail  to  obtain  all  that  is  necessary  to  health. 

This  fact  regarding  the  premature  activity  of  the  sexual  system 
appears  to  arise  from  a  law  in  Kature,  which  is  that  all  plants  and 
animals  placed  in  unfavorable  environments  devote  more  of  their 
energies  to  reproduction  than  those  that  are  more  favorably  situated. 
It  would  appear  as  if  they  appreciated  their  danger  of  being  crowded 
out  of  existence,  and  hence  sti'uggle  more  vigorously  to  procreate. 
Viewing  the  subject  in  this  light  it  may  be  said,  to  speak  figurative- 
ly, that  girls  and  plants  while  stunted  by  living  in  poor  soil  run  to 
seed. 

The  same  premature  menstruation  occasionally  occurs  among 
those  who  are  favoi-ably  situated  in  regard  to  the  necessities  of  animal 
life.  Those  who  have  the  means  of  supplying  all  their  wants,  real 
or  imaginary,  and  lack  intelligence  and  culture,  which  would  enable 
them  to  profitably  occupy  their  minds,  suffer  like  the  poor.  This 
would  indicate  that  the  real  cause  of  the  sexual  precocity  was 
deranged  innervation. 

Delay  of  the  advent  of  menstruation  occurs  among  those  who 
are  situated  apparently  like  those  just  described.  The  girl  who 
labors  out-of-doors  and  develop?  great  muscular  strength  may  fail  to 
menstruate  until  past  the  usual  age.  So,  also,  the  same  thing  occurs 
to  some  who  live  in  luxury.  In  such  cases  the  cause  is,  no  doubt, 
imperfect  innervation.  In  the  class  first  described  attention  is  given 
to  the  genital  system  prematurely,  while  in  the  second  class  the 
social  element  of  life  is  neglected. 

The  general  management  of  these  patients  consists  in  removing 
the  cause,  if  possible,  by  placing  them  in  such  healthful  surround- 
ings as  will  prevent  the  evil.  This,  however,  is  not  always  in  the 
powder  of  the  physician,  and  he  has  to  meet  the  wants  of  those  really 
in  suffering.  When  the  menstrual  function  has  been  established, 
though  prematurely,  no  effort  should  be  made  to  stop  it.  Attention 
should  be  given  wholly  to  building  up  the  general  system.  The 
overworked  should  obtain  rest  and  good  food.  The  nervous  system 
should  have  attention.  The  perverted  mind-action  should  be  cor- 
rected by  wholesome  brain-occupation.  The  indolent  should  be 
stimulated   to   greater  activity.     Society  is  desirable   for  those   in 


ARREST   OF   DEVELOPMENT.  49 

whom  the  menses  are  delayed,  and  quiet  country  life  should  he  pre- 
scribed for  those  who  have  suffered  from  premature  social  excite- 
ment. 

ILLUSTRATIVE   CASES. 

Premature  Menstruation  from  Deranged  Innervation,  produced  by 
Luxurious  Surroundings  and  Over-Stimulation  of  the  Nervous  System. 

— The  2)atient  was  an  only  daughter  of  wealthy  parents,  and  was  al- 
ways a  bright  child  and  greatly  indulged  by  her  family  and  friends. 
She  was  treated  at  home  and  at  school  more  like  a  young  lady  than 
a  child,  and  was  almost  constantly  in  company.  In  the  parlor  and 
drawing-room  she  associated  with  her  elders,  and  was  devoted  to  the 
opera  and  theatre  from  the  time  she  was  big  enough  to  visit  such 
places  of  amusement.  She  often  suffered  from  headaches  and  indi- 
gestion, and  was  always  excitable  mentally,  and  at  times  peevish 
and  irritable.  She  menstruated  first  at  eleven  years  quite  freely, 
and  the  tio^v  lasted  four  days.  At  this  time  she  had  all  the  ap- 
pearances of  girlhood.  The  mammary  glands  were  slightly  de- 
veloped, but  her  form  had  not  attained  anything  like  maturity. 
From  this  time  onward  she  menstruated  regularly  and  normally. 
She  was  first  seen  during  her  first  menstrual  period,  and  then  her 
parents  were  advised  to  change  all  her  habits  of  life.  She  was  taken 
to  a  quiet  country  home  in  sunnner,  instead  of  a  fashionable  hotel 
at  which  she  had  previously  passed  her  summers,  and  permitted  to 
spend  her  time  in  the  fields  with  her  attendant,  who  was  a  woman 
of  good  common  sense  and  experienced  in  the  proper  care  of  chil- 
dren. All  excitement  was  kept  from  her,  and  her  habits  of  life 
made  regular  and  natural.  In  winter  she  was  permitted  to  attend 
school  for  half  the  time,  and  the  rest  of  the  day  was  devoted  to  draw- 
ing, reading,  and  gymnastic  exercises.  Abimdance  of  sleep  in  the 
early  part  of  the  night  was  directed,  and  cold  bathing  every  morn- 
ing. No  medicine  was  given.  Under  this  general  management  she 
grew  in  size  quite  rapidly,  and  by  the  time  she  was  sixteen  years  old 
she  was  a  well-developed  young  lady,  and  enjoyed  very  good  health. 
Premature  Menstruation  occurring  in  a  Poor,  Ill-cared-for  Girl, 
from  the  Lowest  Grade  of  Society. — This  patient,  a  hospital  one,  was 
ten  years  and  five  months  old  when  she  first  menstruated.  She  lived 
in  one  of  the  poorest  tenement  regions  of  the  city.  Her  father  was 
a  drunkard,  and  left  his  family  to  the  care  of  the  mother,  who  was 
a  washer- woman.  This  girl  lived  by  begging  while  very  small,  and 
when  older  worked  in  a  tobacco-factory.  She  was  thirteen  years  old 
when  seen  in  the  hospital,  and  had  menstruated  regularly  from  the 
age  mentioned.  Her  general  health  was  poor,  very  poor ;  she  had 
5 


50  DISEASES   OF   WOMEN. 

the  iippearance  of  an  undersized,  ill-fed,  undeveloped  girl,  quite 
ignorant,  and  doubtless  of  low  moral  nature.  She  was  in  the  hospi- 
tal to  he  treated  for  sjiecitic  vaicinitis. 

Delayed  Menstruation  in  a  Girl  who  was  large,  strong,  and  in  good 
health. — The  daughter  of  a  poor  farmer  had  spent  most  of  her  life 
in  doing  out-door  farm-work.  Her  fcjod  wa.s  milk,  oatmeal,  and 
potatoes.  She  was  large,  muscular,  and  full-blooded.  Between  six- 
teen and  seventeen  years  of  age  she  developed  the  characteristics  of 
womanhood,  but  at  the  age  of  seventeen  years  and  six  months  the 
menses  had  not  appeared.  She  was  then  siitfering  from  occasional 
headaches,  backache,  drowsiness,  constipation,  and  general  indisposi- 
tion. These  sym])toms,  with  delay  in  the  appearance  of  the  menses, 
caused  her  to  seek  advice.  She  was  very  muscular  and  tine-featured. 
The  pulse  was  full  and  strong,  the  mammary  glands  well  developed, 
and  her  figure  was  markedly  of  the  female  type.  A  teaspoonful  of 
sulphate  of  magnesia  and  half  a  teaspoonful  of  table-salt  in  a  goblet- 
ful  of  water  were  ordered  every  morning  an  hour  before  breakfast. 
The  liberal  use  of  animal  food  was  directed.  She  was  advised  to 
take  a  vacation  from  her  hard  labor  on  the  farm,  and  visit  her  rela- 
tions who  were  more  comfortably  situated.  These  directions  were 
followed  out  for  a  month,  with  no  effect,  except  to  relieve  her  con- 
stipation. The  saline  mixture  was  stopped  and  the  following  or- 
dered: Quinige  sulpli.,  3i;  ext.  belladonnae,  gr.  ij;  ext.  aloes  aq., 
gr.  iv.  Pil.  no.  xx  :  one  before  each  meal.  When  the  headache  and 
general  feelings  of  malaise  returned,  I  ])rescribed  spiritus  amnion, 
aroni.,  ^ss;  aquae  camph.,  sijss  —  a  dessertspoonful  every  three 
hours.  At  the  end  of  two  months,  she  began  to  menstruate. 
There  was  considerable  pain  accompanying  the  flow,  which  was 
rather  dark  in  color.  The  pills  were  continued,  but  she  was  soon 
able  to  give  up  one  a  day,  and  then  two,  and  finally  cease  taking 
them  altogether.  At  each  period,  which  recurred  regularly,  she  took 
the  ammonia  and  camphor  mixture.  Six  months  after  her  first  men- 
struation she  reported  that  she  was  regular  and  (|ulte  well. 

Delayed  Menstruation  in  a  Patient  of  Marked  Phlegmatic  Tem- 
perament and  Indolent  Habits.— The  daughter  of  wealthy  parents,  of 
average  height  but  quite  stout,  and  presenting  all  the  evidences  of 
the  phlegmatic  temperament,  was  brought  to  me  at  the  age  of  six- 
teen, because  she  had  not  menstruated.  I  learned  that  she  lived 
well,  slept  much,  and  took  but  little  exercise,  mental  or  physical. 
She  had  all  the  appearance  of  having  arrived  at  j^uberty,  and  for  one 
year  had  had  a  slight  leucorrhoea,  but  no  menstrual  flow.  She  was 
ordered  to  take  lessons  in  horseback-riding,  and  to  walk  for  half  an 


ARREST   OF   DEVELOPMENT.  51 

hour  twice  a  day.  A  Turkish  butli  with  thorough  massage  tliree 
times  a  week  was  also  directed  ;  1  prescribed  potass,  permanganat.,  gr. 
XXX,  in  pil.  no.  xxx :  one  three  times  a  day,  before  meals.  This 
treatment  was  continued  for  about  three  mouths,  excepting  that  at 
the  end  of  one  month  the  pills  were  omitted  for  three  weeks  and 
again  taken  up,  and  continued  until  the  end  of  the  three  months. 
At  this  time  she  menstruated,  and  continued  to  do  so  regularly  after- 
ward. The  flow  was  never  very  free,  but  it  continued  about  five 
days  each  time. 

Irregular  Menstruation  from  Deranged  Innervation  and  Anaemia. — 
This  patient  was  twenty-five  years  of  age,  of  sanguine,  nervous  tem- 
perament, and  had  been  in  good  health  up  to  the  time  that  she 
was  nineteen.  She  menstruated  first  at  fifteen,  and  continued  to 
do  so  regularly,  until  the  year  that  she  graduated  in  school,  when 
nineteen  years  old.  During  the  latter  half  of  her  last  year  in 
school  her  menses  became  irregular,  six  weeks  or  two  months  in- 
tervening between  the  periods.  At  this  time  her  health  became 
much  reduced,  but  after  leaving  school  she  improved  generally,  and 
the  menses  became  regular.  At  twenty -four  years  of  age  she  began  to 
indulge  to  excess  her  love  for  music  and  painting,  which  had  always 
been  favorite  studies  with  her.  Dyspepsia  and  general  debility  fol- 
lowed, and  the  menses  became  again  irregular.  She  first  came  under 
my  care  at  twenty-five,  and  at  that  tune  the  menses  had  been  absent 
for  three  months.  She  was  quite  ansemic,  and  her  nervous  system 
much  exhausted.  She  was  ordered  to  give  up  her  favorite  studies, 
and  devote  herself  to  regaining  her  lost  health.  She  was  directed  to 
take  three  regular  meals  a  day,  and  in  the  forenoon  a  cup  of  beef- 
tea  or  a  glass  of  milk,  and  in  the  afternoon  extract  of  malt,  or  else 
peptonized  milk  and  a  glass  of  claret.  Before  her  regular  meals  she 
was  given  tr.  nucis  vom.,  ill  iij  ;  vini  ipecac,  vi  ij,  in  a  wine-glass 
of  warm  water.  This  improved  her  appetite.  After  meals  she 
took  a  teaspoonful  of  the  following:  Tr.  ferri  chlor.,  3 iij;  liq.  ar- 
senic, hydrochlor.,  3  j  ;  spiritns  limonis,  3  ss ;  syr.  simp.,  ^  j  ;  aquae 
font.,  ^  ij.  This  treatment  was  continued  for  three  weeks,  with  the 
effect  of  improving  her  general  condition,  but  the  menses  did  not 
retura.  In  place  of  the  iron-mixture  she  was  given  the  permangan- 
ate of  potash  pills,  but  without  any  apparent  effect.  Iron  was  again 
given,  and  the  menses  returned  after  she  had  been  six  weeks  under 
treatment.  She  continued  to  be  irregular,  some  five  and  six  weeks 
between  the  periods,  but,  as  her  general  health  improved,  the  inter- 
menstrual periods  became  shorter,  until  the  normal  time  was  estab- 
lished.    Altogether  she  was  under  observation  for  one  year,  and 


62  DISEASES   OF   WOMExM. 

during  most  of  that  time  slie  took  tonics  containing  some  form  of 
iron.  Citrate  of  iron  and  (juinine,  iodide  of  iron  and  whisky,  po- 
tassio-tartratc  of  iron  and  wine,  were  the  cliief  ])rcjiarations  ^riven. 

Suppression  of  the  Menses  from  Acute  Derangement  of  Innervation. 
— A  lady,  twenty-one  years  of  age,  of  excellent  physique,  who  had 
menstruated  with  great  regularity  from  the  time  that  she  was  fifteen 
years  of  age,  left  home  for  the  iirst  time  in  her  life  to  visit  some 
friends  in  a  far-distant  city.  On  the  day  that  her  menses  should 
have  appeared,  she  was  alone  and  not  accustomed  to  traveling,  and 
she  became  much  excited  over  her  journey,  and  was  greatly  fatigued 
when  she  reached  her  friends.  She  could  not  sleep  on  the  cars,  and 
her  appetite  left  her  almost  altogether.  I  was  called  to  her  on  the 
third  day  after  she  left  home,  and  a  few  hours  after  her  arrival. 
The  menses  had  not  appeared  ;  her  head  ached  very  acutely  ;  her  face 
was  flushed ;  skin  dry  and  puls3  excited.  The  temperature  was 
100°  Fahr.  1  ordered  a  hot  foot-bath  and  the  forehead  bathed  with 
alcohol,  and  prescribed  ammon.  bromid.,  gr.  xv,  tinct.  acouit.  rad.,  fii 
ij,  every  three  hours  in  a  small  glass  of  Vichy  water.  She  was  kept 
quiet  in  bed.  After  taking  three  doses  of  the  medicine,  she  slept 
fairly  well  during  the  night.  Next  morning  her  headache  was 
almost  gone ;  her  pulse  was  quiet ;  flushing  of  the  face  less  notice- 
able, and  she  had  an  appetite,  but  the  menses  had  not  come.  I  pre- 
scribed camph.,  gr.  v  ;  ext.  lupul.,  gr.  x  ;  ext.  valerian,  gr.,  x :  in  cap- 
sul.  No.  X.  One  to  be  given  every  three  hours  during  the  day  and 
following  night  if  awake.  She  slept  well  in  the  night  and  next 
morning  began  to  menstruate. 

Amenorrhoea  from  Chronic  Derangements  of  Innervation. — This 
patient  was  twenty-four  years  of  age,  of  good  constitutiun,  and  had 
menstruated  normally  until  six  months  before  the  taking  of  this  his- 
tory. In  that  time  she  lost  her  mother,  to  whom  she  was  greatly 
devoted.  This  prostrated  her  with  grief,  and  about  the  same  time 
her  father  suffered  reverses  in  business,  so  that  my  patient,  who  had 
up  to  this  time  lived  in  luxury,  Wiis  obliged  to  seek  empk»yment  to 
support  herself.  From  the  death  of  her  mother  she  failed  to  men- 
struate until  nine  months  afterward.  She  was  greatly  depressed  up 
to  the  time  that  she  began  treatment,  and,  although  her  general 
health  was  good,  she  was  melancholy,  and  was  greatly  annoyed  by 
her  new  occupation  and  changed  social  position.  The  amenorrhoea 
was  a  gieat  source  of  anxiety  to  her,  because  some  of  her  friends 
had  told  her  that  it  was  sure  to  lead  to  consumjition.  I  fully  assured 
her  that  she  was  in  no  danger,  and  that  her  recovery  was  certain. 
This  alone  was  a  decided  tonic. 


ARREST   OF  DEVELOPMENT.  53 

I  ordered  tlie  following :  Strychnife  snlphatis,  gr.  ss  ;  tr.  cannabis 
Indie.,  3  ij  ;  tr.  card,  comp.,  3  j  ;  aquae  font,,  ^  ij.  Teaspoonful  be- 
fore meals.  This  she  continued  for  two  weeks.  I  then  ordered 
Parrisli's  compound  sirup  of  phosphates,  a  teaspoonful,  after  meals, 
in  water.  This  was  taken  regularly  for  three  weeks,  when  the  fol- 
lowing was  given  instead:  Quin.  sulph.,  3ij;  ext.  valerian.,  3j; 
cxt.  cannabis  Indic,  gr.  v :  in  capsul.  No.  xxi.  One  before  meals, 
and  a  glass  of  red  wine  after  meals.  This  was  continued  for  over  a 
month.  During  this  time  she  v/as  induced  to  take  more  out-of-door 
exercise,  and  divert  her  mind  by  light  amusements.  General  gym- 
nastic exercise  was  taken,  but  not  systematically  nor  regularly.  A¥hen 
this  course  of  treatment  had  been  employed  she  menstruated,  and 
from  this  time  on  was  regular  and  well.  In  general  spirits  she 
began  to  improve  considerably  before  the  menses  returned,  but  after- 
ward her  progress  was  rapid,  and  recovery  complete.  This  case  will 
suffice  to  illustrate  this  cause  of  amenorrhcea. 

Imperforate  Hymen  causing  If  on-appearance  of  the  Menstrual  Flow. 
— This  affection  should  be  classed  with  atresia  of  the  vagina,  but  is 
given  here  because  the  history  of  such  cases  resembles  delayed  men- 
struation from  some  of  the  causes  just  given.  This  condition  is 
usually  unnoticed  until  puberty,  when  all  the  evidences  of  menstrua- 
tion appear  except  the  flow,  which  is  arrested  by  the  imperforate, 
thickened  hymen.  The  fluid  w^iich  accumulates  at  each  menstrual 
period  distends  the  vagina  first  and  then  the  uterus,  the  distention 
increasing  at  each  period.  Pelvic  tenesmus  and  a  feeling  of  disten- 
tion of  the  vagina  and  enlargement  of  the  abdomen  are  the  chief 
symp'  oms  and  signs  presented. 

In  course  of  several  months  the  suffering  causes  the  patient  to 
seek  relief,  when  a  diagnosis  can  be  made  by  physical  examination. 
The  treatment  is  to  evacuate  the  fluid  by  opening  through  the 
hymen.  This  is  attended  with  great  danger,  owing  to  the  tendency 
to  inflammation  and  septicaemia.  The  fluid  is  dark,  thick,  and  tarry 
in  character,  and  decomposes  quickly  on  exposure  to  air.  This  and 
the  irritation  of  the  vagina  and  utei'us  may  account  for  the  tendency 
to  inflammation  and  blood-poisoning.  The  method  of  treatment 
found,  in  past  times,  to  be  the  safest  was  to  make  a  small  opening, 
evacuate  very  slowly,  and  subsequently  enlarge  the  opening,  or  ex- 
sect  the  hymen  entirely.  Another  method  is  to  make  a  free  incision, 
evacuate  rapidly,  and  wash  out  the  uterus  and  vagina.  This  method 
has  jiroved  to  be  safer  since  the  days  of  antiseptic  surgery,  and  may 
be  adopted. 


CHAPTER   IV^. 

FLEXIONS    OF   THK    UTERUS. 

I  CONSIDER  flexion  of  the  uterus  us  a  deformity,  and  it  certain- 
ly belongs  to  that  order  of  pathological  conditions.  The  pathol- 
ogy, cause,  symptoms,  physical  signs,  and  treatment  of  flexion,  all 
differ  from  vei'sion,  hence  a  clear  distinction  between  the  two  should 
be  made  in  order  to  avoid  confusion. 

Anteflexion  of  the  uterus  is  most  frequently  a  congenital  deform- 
ity, some  arrest  or  derangement  of  development  giving  rise  to  the 
malformation.  Occasionally  it  results  from  disease,  inflammatory 
or  degenerative,  which  weakens  the  utei'us  at  a  certain  point  and 
permits  it  to  become  bent  upon  itself.  I  shall  limit  myself  to  the 
consideration  of  flexion  occurring  as  the  result  of  these  two  causes, 
and  shall  purposely  omit  all  deformities  caused  by  pi-e-existing  aflfec- 
tions,  such  as  adhesions  of  the  uterine  body  to  other  pelvic  organs, 
tumors  in  the  walls  of  the  uterus  wliich  by  their  weight  bend  the 
uterus,  and  pressure  of  abdominal  tumors  which  crowd  the  uterine 
body  to  either  side.  Whenever  flexion  is  produced  by  some  such 
antecedent  disease,  I  prefer  to  consider  it  as  a  complication  of  the 
primary  affection,  rather  than  to  discuss  it  as  a  distinct  condition. 

The  point  of  flexion  is  at  the  junction  of  the  body  and  cervix. 
It  may  occur  above  or  below  that  point,  but  only  as  a  very  unim- 
portant exception  to  the  rule.  The  several  forms  of  flexion  I  have 
denominated  flrst,  second,  and  third.  The  flrst  is  flexion  of  the 
body ;  the  second,  flexion  of  the  cervix ;  and  the  third,  flexion  of 
both  body  and  cervix. 

Taking  the  ground  that  flexion  is  a  defoi-niity,  it  may  naturally 
be  attrilnited  to  some  defect  of  development ;  and  in  order  to  un- 
derstand the  lesions  of  form  and  structure  arising  from  arrest  or 
derangement  of  development,  it  becomes  necessary  to  restate  the 
essential  points  in  that  process  as  relates  to  the  uterus. 

At  l)irth  the  uterus  and  vagina  are  joined  in  such  a  manner  that 


FLEXIONS  OF  THE   UTERUS.  55 

the  cervix  uteri  projects  into  tlie  vagina  but  a  very  short  distance, 
and  about  equally  on  the  anterior  and  posterior  walls  of  the  vagina. 
After  birth  the  uterus  remains  without  change  until  [)ubarty,  ex- 
cept during  the  time  of  second  dentition,  when  the  ])alma  })licata 
disappears  from  the  body  of  the  organ,  with  the  exception  of  one 
fold  which  runs  lengthwise.  The  body  increases  a  little  in  size,  so 
that  the  body  and  cervix  become  more  nearly  equal.  At  the  same 
time  the  organ  settles  down  into  the  pelvic  cavity,  and  the  cervix 
elongates  and  becomes  more  prominent  in  the  vagina. 

At  puberty  the  uterus  undergoes  secondary  development.  The 
organ  increases  in  size,  this  being  especially  true  of  the  body.  Un- 
til puberty  the  uterus  differs  but  little  in  shape  from  that  of  the 
new-born  babe,  which  has  been  already  described ;  but  at  the  time 
when  menstruation  or  functional  activity  of  the  reproductive  organs 
is  about  to  be  established,  it  assumes  the  foi-m  and  structure  of  the 
mature  organ.  Suffice  it  to  say  that,  as  the  tissues  are  developed, 
they  become  denser,  giving  to  the  organ  the  firmness  necessary  to 
support  it  and  keep  it  from  bending  in  any  direction  by  its  own 
weight. 

There  are  two  anatomical  points  bearing  upon  the  subject  now 
under  consideration  to  which  I  desire  to  call  particular  attention : 

1.  The  position  or  relations  of  the  uterus  to  other  pelvic  organs 
at  birth,  during  girlhood,  and  after  puberty. 

2.  The  relations  of  the  cervix  uteri  and  the  vagina  at  the  com- 
pletion of  primary  formation  and  after  secondary  development. 

The  infantile  pelvis  is  relatively  narrower,  deeper,  and  less  curved 
than  the  adult ;  hence  the  canal  formed  by  the  uterus  and  vagina  is 
straighter  than  after  puberty.  The  small  size  of  the  infantile  uterus, 
the  thinness  of  its  walls,  and  flaccid  condition  of  its  tissues,  render  it 
capable  of  bending  forward  or  backward  according  to  circumstances. 
This  fact  may  account  for  the  variety  of  opinions  regarding  the 
position  of  the  uterus  previous  to  puberty.  At  birth  the  uterus  is 
high  up  in  the  pelvis,  but  settles  down  during  the  second  dentition, 
as  has  been  already  stated,  and  forms  with  the  vagina  the  arc  of  a 
smaller  circle,  having  its  concavity  forward;  hence  the  greater 
Hability  of  the  uterus  to  be  anteflexed  or  anteverted  during  girl- 
hood, if  it  deviates  at  all ;  but,  according  to  Klob,  the  uterus  is 
neither  bent  forward  nor  backward  until  puberty. 

From  the  information  obtained  by  the  study  of  embryology  and 
the  anatomy  of  the  reproductive  organs,  one  must  necessarily  con- 
sider the  uterus  and  vagina  as  forming  one  canal.  The  pecuHar  ar- 
rangement at  the  junction  of  these  organs  appears  as  if  formed  from 


56  DISEASES   OF   WOMEN. 

;in  invagination,  the  upper  part  of  the  vagina  receiving  the  (hipli- 
eation  of  the  uterus  wliieh  forms  the  vaginal  portion  of  the  cervix. 
This  invagination  is  very  slight  at  birth,  as  may  be  seen  by  referring 
to  any  normal  infantile  uterus.  The  projecting  portion  of  the  cervix 
at  this  period  is  about  equal,  anteriorly  and  posteriorly.  iJuring 
the  period  of  second  dentition,  when  the  uterus  settles  down,  this 
portion  of  the  cervix  becomes  more  apparent  still.  It  will  also  be 
observed  that  the  posterior  wall  of  the  cervix  projects  a  little  farther 
than  the  anterior.  At  puberty,  when  the  sexual  organs  undergo 
secondary  development,  invagination  progresses  still  further,  and  the 
cers'ix  and  vagina  assume  the  relation  of  adult  maturity.  It  should 
be  noted  that  the  portion  of  the  cervix  whicli  projects  into  the 
vagina  is  much  longer  posteriorly  than  antenorly.  This  nmst  neces- 
sarily be  so,  to  some  extent,  from  the  fact  that  the  uterus  and  vag-ina 
form  an  arc  of  a  circle  corresponding  to  the  curve  of  the  pehis ;  but 
the  difference  is  slightly  greater  than  is  necessary  to  make  the  curve 
form  part  of  a  circle.  Perhaps  it  would  be  more  correct  to  say  that 
the  junction  of  the  cervix  and  vagina  forms  an  obtuse  angle. 

I  am  thus  particular  in  describing  these  relations  of  the  uterus 
and  vagina,  because  I  hope  to  show  hereafter  that  arrest  or  derange- 
ment of  the  process  of  invagination  of  the  cervix  uteri  has  much  to 
do  in  causing  flexion. 

Anteflexion  of  the  Uterus.— I  prefer  to  consider  anteflexion  of 
the  uterus  a  deformity,  although  it  is  usually  called  a  displacement, 
because  it  certainly  is  a  lesion  of  form  rather  than  jiosition. 

The  pathology,  cause,  symptoms,  physical  signs,  and  treatment  of 
flexion  all  differ  from  those  of  displacements  of  the  uterus,  hence 
the  clearer  that  the  distinction  between  the  two  can  be  made  the 
better. 

The  deformities  which  occur  at  puberty  are  perhaps  more  fre- 
quently lesions  of  size  or  quantity  from  arrest  of  growth  than 
lesions  of  form  from  arrest  of  development.  During  secondary 
development  the  infantile  uterus  is  transformed  into  that  of  the 
adult  chiefly  by  the  increase  in  the  size  of  the  body  and  fundus, 
and  the  dipping  down  of  the  cervix  into  the  vagina.  When  these 
changes  do  not  take  place  properly,  esjiecially  if  the  invagination 
of  the  cervix  is  arrested,  the  uterus  becomes  flexed  ujion  itself. 
Other  causes  of  this  malformation  there  are  which  will  be  again  re- 
ferred to. 

Anteflexion  of  the  uterus  is  usually  a  congenital  deformity, 
caused  by  arrest  of  development  occurring  dui-ing  the  later  stages 
of  that  process.     It  is  inferred  from  the  clinical  history  of  flexion 


FLEXIONS   OF   THE    UTERUS. 


that  it  is  congenital,  but  this  is  not  perliaps  strictly  true  of  all  the 
cases  that  occur  as  primary  lesions.  I  presume  that  most  frequeritly 
the  malformation  takes  place  during  secondary  development  at 
puberty.  Occasionally  it  comes  from  some  pre-existing  disease,  in- 
tlannnatory  or  degenerative,  which  weakens  the  walls  of  the  uterus 
at  the  junction  of  the  body  and  cervix  and  permits  it  to  become 
bent  upon  itself.  Retroliexion  often,  perhaps  generally,  is  devel- 
oped from  retroversion,  the  one  holding  a  causative  relation  to  the 
other,  but  this  form  of  acquired  flexion  will  most  conveniently 
come  under  the  head  of  retroversion  and  its  complications. 

Clinically  considered  in  relation  to  causation  there  are  two  classes : 
the  congenital,  called  so  because  it  is  usually  first  recognized  at  pu- 
berty ;  and  acquired,  because  it  generally  appears  after  puberty  and 
follows  some  previous  uterine  disease  either  inflammatory,  or  a  mal- 
nutrition which  reduces  the  quantity  of  tissue  at  a  given  point,  and 
permits  the  uterus  to  bend  upon  itself.  Flexions  from  these  two 
causes  constitute  a  class  by  themselves,  and  therefore  they  alone 
will  be  treated  of  in  this  connection.  Flexions  occur  in  connection 
with  other  afliections,  such  as  adhesions  of  the  body  of  the  uterus  to 
other  pelvic  organs ;  tumors  in  the  walls  of  the  uterus,  which,  by 
their  weight,  bend  the  uterus  upon  itself ;  and  pressure  from  ab- 
dominal tumors  which  crowd  the  uterine  body  out  of  place ;  but 
flexion  in  such  cases  is  only  a  complication  of  the  affection  which 
causes  it,  and  does  not  belong 
to  the  subject  of  flexion  as  a 
primary  lesion.  Theoretically, 
the  uterus  might  become 
flexed  in  either  direction; 
but  practically  the  forward 
and  backward,  anteflexion  and 
retroflexion,  are  the  only  two 
forms  that  occur  as  uncom 
plicated  affections.  The  later- 
al flexions  are,  as  a  rule,  sec- 
ondary to  the  diseases  already 
mentioned. 

Anteflexion,  which  occurs 
as  the  result  of  imperfect  de- 
velopment, and  which  is  oc- 
casionally acquired  from  mal- 
nutrition, is  by  far  the  most  connnon.  There  are  three  varie- 
ties of  anteflexion :   First,  forward  flexion  of  the  cervix  (Fig.  34) ; 


Fig.  34. — First  variety  ;  antoflcxion  of  cervix. 


58 


DISEASES   OK    WOMEN. 


Fig.  35.- 


-Second  variety ;    anteflexion  of  body  of 
uterus. 


second,  forward   flexion  of  the  body  (Fi^.  '*>5) ;  jiiid,  third,  lorwurd 
flexion  of  both  body  and  cervix  <  I^'ig.  36). 

Pdtholotjy. — Flexion  of 
any  form  neces.sitates  some 
defect  in  the  structure  of 
the  uteru.s,  Tiiis  consititutes 
one  of  the  essential  differ- 
ences between  flexion  and 
version,  which  latter  is  sim- 
ply an  error  of  location 
without,  necessarily,  any 
change  of  structure  of  the 
uterus.  The  flexion  is  usu- 
ally at  the  junction  of  the 
body  and  cervix,  the  point 
corresponding  to  the  inter- 
nal OS.  Flexion  at  any  point 
in  the  body  or  cervix  oc- 
curs only  as  an  exception, 
which  need  not  be  noticed  here.  At  the  point  of  flexion  the  tissues 
of  the  uterine  walls  are  deficient.  On  the  side  to  which  the  organ  is 
bent  the  wall  is  compressed  and  attenuated.  On  the  other  side  the 
loss  of  tissue  is  not  so  marked, 
the  thickness  being  but  slight- 
ly diminished  by  the  stretch- 
ing. The  sub-mucous,  fibrous 
stratum  of  tissue,  whieli  is 
said  to  give  firmness  and  sup- 
port to  the  organ,  is  absent  or 
deficient  on  the  side  to  which 
the  uterus  is  l)ent. 

The  effect  of  flexion  on 
the  uterine  canal  is  to  produce 
constriction  or  occlusion  of 
the  internal  os.  The  external 
OS  is  sometimes  more  open 
than  in  health,  owing  to  trac- 
tion being  made  on  tlie  pos- 
terior lip.  The  stricture  thus 
formed  gives  rise  to  accumu- 
lation of  the  secretions  of  the  uterine  eavit}',  and  to  partial  retention 
of  the  menstrual  ])roducts.     The  circulation  in  the  uterus,  as  will  be 


Fio.  36. 


Third  variety  ;  anteflexion  of  body  and 
cervix. 


FLEXIONS   OF   THE    UTERUS.  59 

readily  understood,  is  interfered  with.  The  ol)stniction  tends  to  keep 
up  congestion,  and  tliis  may  eventually  lead  to  (jedema  and  a  predis- 
position to  endometritis  and  pelvic  peritonitis. 

From  all  these  causes  derangement  of  function  follows.  The  men- 
strual Huid,  in  place  of  escaping  passively,  is  expelled,  perhaps,  by 
spasmodic  contractions,  attended  with  colicky  pain.  In  other  words, 
there  is  dysmenorrhoea.  Sterility  also  exists  in  the  majority  of  cases. 
These  pathological  conditions  increase  with  time.  The  pressure  at 
the  point  of  flexion  produces  anaemia  and  atrophy  of  that  part,  and 
the  intrinsic  support  of  the  uterus  l)eing  thus  diminished  the  flexion 
increases.  Hence,  the  flexion  of  the  first  variety  often  progresses  to 
the  second  and  third. 

The  anatomical  appearances  in  flexion  are  well  described  in  Nie- 
meyer's  "  Text-Book  of  Practical  Medicine."  I  quote  that  portion 
which  applies  to  anteflexion  of  the  body  of  the  uterus  :  "  On  autopsy, 
flexion  of  the  utenis  may  be  readily  recognized,  as  part  of  the  pos- 
terior wall  of  the  body,  instead  of  the  fundus,  forms  the  highest  part 
of  the  uterus.  Generally,  we  may  restore  the  sunken  fundus  to  its 
position,  but  it  sinks  back  again  to  its  former  place  when  we  let  go 
of  it.  If  we  cut  the  uterus  out  of  tlie  body,  and  hold  it  erect  by  the 
vaginal  portion,  the  fundus  sinks  down  anteriorly ;  if  it  be  held 
hoi-izontally,  it  not  infrequently  holds  its  weight  if  the  flexed  side 
be  upward,  but  it  bends  together  if  we  reverse  it."  To  this  I  would 
add  that  in  tbe  first  variety  the  cervix  projects  into  the  vagina  much 
farther  on  the  posterior  wall  than  on  the  anterior ;  indeed,  in  marked 
cases,  the  anterior  lip  of  the  cervix  uteri  is  very  little  below  a  line 
corresponding  to  the  point  of  union  between  the  cervix  and  the  an- 
terior vaginal  wall. 

Natural  History  of  Anteflexion. — Sym2)tomatology. — Derangement 
of  uterine  function  constitutes  the  principal  point  in  the  natural  his- 
tory of  flexion.  Menstruation,  from  its  first  establishment,  is  often 
painful — there  is  dysmenorrhoea.  The  severity  of  the  pain  bears 
some  relation  to  the  extent  of  flexion.  The  greater  the  deformity 
the  more  marked  is  the  pain,  thougb  there  are  exceptions  to  this  rule. 
The  character  of  the  pain  is  of  the  greatest  importance.  It  is  inter- 
mittent, and  always  precedes  the  flow,  \yhen  the  flow  begins,  the 
pain  either  subsides  or  becomes  much  less.  The  pain  closely  resem- 
bles that  which  occurs  in  abortion  in  the  early  months  of  pregnancy. 
The  reason,  I  presume,  is  tliat  while  the  fluid  is  accumulating  in  the 
uterine  cavity,  })ain  is  excited  by  distention  ;  but  the  flow  when 
once  started,  continues  with  less  expulsive  eflbrt.  Painful  men- 
struation often  occurs  without  flexion,  but  in  such  cases  the  pain 


60  DISEASES   OF   WOMEN. 

continues  throughout  the  whole  periud,  or  during  the  early  part  of 
it,  and  is  not  relieved  by  dilatation  of  the  cervix;  while  in  tiexion 
it  precedes  the  flow,  and  is  relieved  temporarily  by  dilatation.  This 
pain,  at  the  coniniencement  of  menstruation,  is  the  most  prominent 
symptom  in  the  history  of  flexion  as  it  occurs  in  the  young  girl.  The 
trouble  tends  to  increase  gradually.  If  the  patient  gets  married,  all 
the  symptoms  usually  increase.  Should  she  become  pregnant,  there 
is  great  liability  to  miscarriage  during  the  early  months.  The  effect 
of  the  pregnancy,  however,  in  part  at  least,  is  to  remove  the  deform- 
ity, even  when  miscarriage  occurs,  so  that  pregnancy  is  likely  to  occur 
again,  and  go  on  to  full  time,  and  the  deformity  is  cured  completely. 
Checking  the  menses  by  exposure  to  cold,  or  any  cause  which  will 
produce  liypertemia  of  the  uterus,  or  endometritis,  promptly  increases 
the  dysmenorrhoea,  and  gives  rise  to  new  symptoms.  Leucorrhoea, 
backache,  local  tenderness,  deranged  digestion,  and  nervous  disturb- 
ances, are  all  added  to  the  original  symptoms.  Sometimes  in  ante- 
flexion frequent  micturition  is  a  marked  symptom. 

There  are  all  varieties  and  degrees  of  prominence  of  the  synn> 
toms  in  the  natural  history  of  flexion.  The  dysmenorrhiea  which 
begins  at  puberty  may  continue,  and  increase  but  little  through  life. 
This  is  most  likely  to  be  the  case  if  the  individual  remains  unmai*- 
ried,  and  can  avoid  all  the  conditions  which  tend  to  aggravate  uter- 
ine disease.  On  the  other  hand,  the  dysmenorrhoea  mav  increase  in 
severity  during  each  succeeding  menstruation,  and  after  marriage 
become  intolerable.  In  the  intervals  between  the  menstrual  periods 
the  patient  in  her  early  life  is  free  from  trouble,  but  eventually 
symptoms  of  uterine  and  vaginal  inflammation  are  manifested. 
Constitutional  derangements,  especially  of  the  nervous  system,  fol- 
low, and  in  time  we  have  the  broken-down,  miserable  patients,  famil 
iar  to  all  practitioners.  Such  patients  often  seek  relief  in  the  use  of 
stimulants  and  opium,  which  only  soothe  for  a  time,  but  eventually 
aid  in  undermining  the  health  and  strength  of  the  unfortunate  suf- 
ferers. 

The  subjects  of  flexion  are  very  liable  to  pelvic  peritonitis  and 
diseases  of  the  ovaries  and  Fallopian  tubes,  with  all  the  suffering 
which  these  affections  give  rise  to. 

Physical  Signs. — Although  the  history  alojie  might  lead  one 
with  a  toleral)le  degree  of  certainty  to  suspect  the  presence  of  flex- 
ion, the  physical  signs  must  be  depended  upon  for  an  accurate  diag- 
nosis. The  physical  signs  of  flexion  arise  from  the  changed  relations 
of  the  body  and  cervix  to  each  other.  These  signs  are  detected  by 
the  touch  and  the  uterine  probe.     The  touch  may  indicate  that  the 


FLEXIONS   OF   THE   UTERUS.  01 

cervix  occupies  its  normal  position,  or  it  may  be  found  to  be  retro- 
verted,  ■which  is  its  most  frequent  position  in  anteflexion.  The  os 
points  toward  the  introitus  in  the  same  vs^ay  that  we  find  it  in  retro- 
version. The  vaginal  portion  of  the  anterior  wall  of  the  cervix  is 
much  shorter  than  the  posterior.  Carrying  the  finger  along  the  an- 
terior vaginal  wall,  the  body  of  the  uterus  can  usually  be  felt  bend- 
ing forward.  The  bimanual  examination  reveals  the  deformed 
condition  of  the  uterus  in  lean  patients,  whose  abdominal  parietes 
are  yielding ;  but  in  fleshy  subjects  with  rigid  abdominal  muscles, 
very  little  can  be  learned  by  this  mode  of  exploration.  When 
rigidity  of  the  parts  is  the  obstacle  to  exploration,  an  angesthetic 
may  be  used  with  great  advantage,  as  practiced  by  Sir  J.  Y.  Simpson. 

When  the  signs  thus  obtained  point  to  flexion,  the  diagnosis 
should  be  confirmed  by  using  the  sound.  Much  trouble  is  often 
experienced  in  introducing  this  instrument.  Indeed,  it  is  impos- 
sible in  extreme  flexion  to  carry  the  sound  into  the  uterus  without 
first  straightening  the  bend  at  the  junction  of  tlie  body  and  cervix. 
To  do  this,  the  cervix  should  be  seized  by  a  tenaculum,  and  gently 
drawn  downward,  while  at  the  same  time  the  fundus  is  pressed  up- 
ward and  backward.  In  this  way  the  canal  is  partially  straightened, 
and  the  sound  can  be  introduced.  There  are  cases  where  it  is  only 
necessary  to  curve  the  sound  properly  and  manipulate  with,  care, 
and  the  point  of  flexion  can  readily  be  passed.  When  the  sound 
passes  into  the  body  of  the  uterus  in  the  direction  indicated  by  the 
touch,  the  diagnosis  is  complete.  While  there  are  many  conditions 
which  might  present  the  signs  of  flexion  as  obtained  by  tbe  touch, 
the  combined  testimony  of  the  touch  and  sound  are  sufficient  to 
make  the  diagnosis  sure. 

Causation. — There  are  several  causes  of  flexion,  which  may  ac- 
count for  the  different  opinions  held  by  authors  on  this  subject. 
The  errors,  I  presume,  come  from  investigators  accepting  the  cause 
found  in  a  limited  number  of  instances  as  applying  to  all  cases  of 
flexion.  Some  of  the  more  important  causes  assigned  may  be  briefly 
noticed. 

Rokitansky  considered  that  the  peculiar  density  and  arrange- 
ment of  the  mucous  membrane  of  the  cervix  and  lower  part  of  the 
corpus  uteri,  formed  one  of  the  chief  supports  of  the  organ,  and  gave 
it  its  slight  anterior  inclination  ;  consequently,  he  looked  upon  the 
pathological  state  of  this  layer  as  the  basis  in  the  development  of 
uterine  flexions.  He  thought  the  uterus  bent  upon  itself,  from  cir- 
cumscribed atrophy  of  one  of  its  walls,  arising  from  inflanmiation. 
He  claimed  that  the  glands  of  the  mucous  membrane,  becoming  dis- 


er2  DISEASES   OF    WOMEN. 

tended  from  iiuj)ri8oned  secretions,  so  pressed  upon  the  other  tissues 
as  to  cause  atrophy  at  that  part.  When  the  distended  glands  rupt- 
ured and  collapsed,  the  part  rendered  thus  defective  permitted  the 
uterus  to  bend  upon  itself.  Several  eminent  writers  on  this  subject, 
Dr.  Ludwio;  Joseph  beinf^  the  most  recent,  after  careful  observa- 
tions, have  been  unable  to  discover  this  peculiar  condition  of  the 
mucous  membrane  and  its  submucous  layer  to  which  Rokitansky 
alludes.  If  they  are  correct,  further  discussion  of  this  supposed 
cause  is  useless.  Should  Rokitansky  be  riglit,  the  cause  he  favors 
would  chieri}'  affect  cases  of  acquired  flexion ;  while  the  majority  of 
cases  occur  before  we  have  any  evidence  that  inflammation  pre- 
ceded it. 

Vircliow  attributes  the  primary  cause  of  flexion  to  congenital 
shortness  of  the  anterior  uterine  ligaments,  which  drag  the  body  of 
the  utenis  forward,  or  flex  it.  The  uterus  being  held  in  this  posi- 
tion, pressure  results,  wdiich  leads  to  atrophy  of  the  tissues,  and  thus 
all  the  conditions  of  flexion  are  present. 

Klob,  who  is  one  of  the  best  authorities  on  uterine  pathology, 
doubts  the  views  expressed  by  Virchow,  and  states  that  wnth  the  nor- 
mal firmness  of  the  tissues  the  uterus  is  not  likely  to  be  deflected  by 
the  cause  in  question.  He  also  calls  attention,  as  a  reason  against  the 
theorv  of  Vircliow,  to  the  fact  that  false  membranes  or  short  li^a- 
ments,  which  would  incline  and  fix  the  fundus  forward,  would  ne. 
cessarily  cause  ]:)ressure  on  the  fundus  of  the  bladder.  This  would 
cause  the  bladder  to  distend  more  in  its  lowest  portion,  which  would 
press  the  lower  part  of  the  cervix  uteri  backward,  and  in  place  of 
producing  flexion  would  cause  anteversion.  Kloli  admits  that  the 
cause  assigned  by  Yirchow  may  produce  or  maintain  flexion,  but 
only  when  there  is  defect  of  tissue  in  the  uterus  itself,  arising  from 
some  anterior  cause. 

The  relation  of  the  bladder  to  the  uterus  is  looked  on  by  some 
writers,  including  Yirchow  and  Ludwig  Joseph,  as  of  some  impor- 
tance in  the  etiology  of  flexion.  The  uterus  is  known  to  make  a 
descent  corresponding  to  the  variations  in  the  shape  of  the  bladder, 
which  in  foetal  and  infant  life  changes  from  the  elongated  fusiform 
to  the  short  ovoid  shape,  and  its  fundus,  thus  approaching  the  floor 
of  the  pelvis,  draws  the  attached  uterus  with  it.  As  the  cervix 
uteri  is  closely  attached  to  the  posterior  surface  of  the  bladder,  it 
will  be  readily  understood  that  perverted  development  in  the  con- 
nections of  the  two  organs  might  lead  to  flexion. 

The  only  causes  which  I  consider  worthy  of  discussion  in  con- 
nection with  anteflexion,  when  it  occurs  as  a  primary  or  uncorapli- 


FLEXIONS   OF   THE    UTERUS.  63 

cated  disease,  are :  1.  Malformation  resulting  from  arrested  or  im- 
perfect development.  Flexion  arising  from  this  cause  may  be  classed 
among  the  congenital  deformities.  2.  Deformities  arising  from  in- 
flammation and  degeneration  of  the  uterine  walls  on  one  side.  This 
will  include  atrophy  of  the  anterior  uterine  wall  at  the  os  internum 
from  inflammation  and  distention  of  the  cervical  glands ;  also  fatty 
degeneration  in  advanced  life,  and  excessive  involution  after  parturi- 
tion, by  which  one  of  the  uterine  walls  is  weakened  at  the  junction 
of  the  cervix  and  body.     These  may  be  called  acquired  flexions. 

I  purposely  omit  a  number  of  conditions  usually  given  as  causes 
of  flexions,  such  as  metritis,  enlargement  of  the  corpus  uteri,  preg- 
nancy, uterine  tumors,  abdominal  tumors,  accumulations  of  fluid  in 
iitero,  ascites,  fecal  accumulations,  and  adhesions  from  inflanmiatory 
exudations.  Several  of  these  causes,  such  as  pregnancy,  produce 
flexion  so  very  seldom  that  they  may  be  treated  as  exceptions  to  the 
ordinary  laws  of  pathology,  and  are  of  no  practical  importance.  The 
others  named  are  more  important  than  the  flexions  which  they  pro- 
duce, and  I  should  prefer  to  discuss  flexion  occurring  under  such 
circumstances  as  a  complication  of  the  primary  affection.  It  is,  to 
say  the  least  of  it,  objectionable  classification,  to  discuss  the  primary 
and  most  important  disease  as  the  cause  of  a  consecutive  affection, 
and  one  which  does  not  always  follow. 

Regarding  the  first  cause — impei'fect  development — I  can  readily 
see  how  flexion  might  occur  therefrom.  During  the  time  when  in- 
vagination of  the  lower  portion  of  the  cervix  and  upper  part  of  the 
vagina  takes  place,  the  process  is  liable  to  progress  farther  on  one 
side  tlian  on  the  other.  Should  the  posterior  vaginal  wall  become 
reflected  much  higher  than  the  anterior,  the  attachment  of  the  vagi- 
na, being  lower  on  the  anterior  surface  of  the  cervix,  would  naturally 
pull  it  forward.  From  the  fact  that  this  malformation  at  the  junc- 
tion of  the  uterus  and  vagina  is  present  in  the  vast  majority  of  cases 
of  anteflexion  of  the  cervix,  I  have  looked  ujjon  it  as  one  important 
cause.  If  this  arrangement  should  tend,  as  it  probably  does,  to  bring 
the  cervix  forward  so  as  to  flex  the  uterus  to  a  slight  degree  previ- 
ous to  its  complete,  development,  the  ]:)ressure  at  the  point  of  flex- 
ion would  arrest  the  growth  at  that  point,  and  then  the  wall  would 
become  more  attenuated  still,  and  flexion  of  the  body  would  be 
produced. 

Imperfect  development  may  cause  flexion  in  another  way. 
The  infantile  uterus,  having  little  strength  of  tissue  to  support  itself, 
might  readily  become  flexed,  and  so  remain  during  the  period  of 
secondary  development.     I  am  aware  that  good  authorities,  such  as 


G4  DISEASES   OF   WOMEX. 

Klub,  .statu  that  previous  to  puberty  the  uterus  is  neither  l)ent  baek- 
ward  nor  forward  ;  but  other  observers  have  found  tlie  infantile 
utenis  antetlexed  in  many  cases,  and  one  can  readily  understand  wliy 
the  organ  might  remain  so.  The  position  in  sitting  at  school  and  in 
sewing  so  often  maintained  by  girls,  constipation,  and  improper  cloth- 
ing, all  tend  to  retard  development  and  hence  j)roduce  flexion.  The 
uterus  might  readily  increase  in  size  at  all  parts  except  the  portion 
compressed  at  the  point  of  flexion. 

Flexion  occurs  also  from  excessive  develo])ment  of  the  cervix. 
The  unnaturally  long  cervix  pressing  upon  the  posterior  wall  of  the 
vagina  is  inclined  forward,  while  the  body  of  the  uteinis  remains  in 
its  normal  axis.  This  produces  slight  flexion,  which  in  time  becomes 
greater,  on  the  principle  that  the  deformity,  once  established,  tends 
to  increase. 

When  flexion  is  caused  by  inflammation,  the  explanation  given 
by  Rokitansky  and  already  referred  to,  applies  in  some  cases  of  ac- 
quired flexion.  Irregular  involution  is  doubtless  one  of  the  causes  of 
flexion  when  it  occurs  after  confinement  or  miscarriage.  If  press- 
ure was  brought  to  bear  on  the  cervix,  fundus,  or  both,  so  as  to  favor 
flexion,  involution  might  go  on  beyond  the  normal  limits  at  the 
point  of  pressure. 

Treatment. — A  brief  review  of  the  various  plans  of  treatment 
will,  I  believe,  show  that  while  they  are  of  great  value,  and  capable 
of  giving  relief  in  many  cases,  still  it  will  be  found  that  they  do  not 
fully  equal  all  demands.  The  use  of  extra-uterine  pessaries  will  re- 
lieve some  of  the  prominent  symptoms,  but  will  not  overcome  the 
deformity.  Intra-utenne  pessaries,  while  they  sustain  the  uterus  in 
its  normal  shape,  are  objectionable  in  some  respects ;  they  are  often 
difficult  to  introduce,  are  not  easily  held  in  position,  and  are  liable 
in  some  cases  to  cause  so  much  irritation  as  to  make  their  prolonged 
use  dangerous  to  life. 

The  surgical  methods  which  have  for  their  object  only  to  relieve 
the  symptoms  or  evil  consequences  of  flexion,  are  chiefly  dilatation 
and  division  of  one  wall  of  the  cervix.  Dilatation  is  certainly  of 
much  value,  but  the  improvement  is  often,  indeed  generally,  only 
temporary.  Division  of  one  of  the  cervical  walls  answers  the  same 
purpose  as  dilatation,  and  the  effect  is  not  more  lasting.  lUit  neither 
of  these  modes  of  treatment  overcomes  the  deformity  altogether,  and 
seldom  permanently  cures  the  troublesome  sym]>toms.  Tlie  ment 
of  dividing  the  cervical  wall  appears  to  me  to  be,  that  it  may  correct 
the  conditions  of  the  flexion  which  cause  sterility,  and  when  that  is 
accomplished,  and  pregnancy  follows,  the  development  of  the  uteras 


FLEXIONS   OF  THE   UTERUS.  65 

(luring  gestation  permanently  cures  the  malformation  as  a  rule.  If 
pregnancy  does  n<^t  follow,  the  patient  is  not  always  improved,  ex- 
cept tem])orarily,  by  the  treatment. 

The  objects  to  be  attained  in  the  treatment  of  flexions  of  the 
uterus  are,  to  straighten  the  organ  and  to  keep  it  so  until  the  defect- 
ive portions  of  its  walls  become  developed  sufficiently  to  render  it 
self-sustaining.  Shonld  the  means  used  fail  to  overcome  the  de- 
formity, the  next  aim  should  be  to  relieve  the  patient  from  the  con- 
secpiences  of  the  flexion  by  other  means,  such  as  dilating  the  canal  of 
the  uterus,  or  dividing  the  posterior  wall  of  the  cervix  after  the 
manner  of  Sims.  The  means  to  be  used  in  the  management  of 
flexion  must  be  adapted  to  each  case,  and  hence  the  subject  resolves 
itself  into,  flrst,  the  treatment  of  flexion  of  the  cervix  ;  second,  flexion 
of  the  body  of  the  uterus  ;  and,  third,  flexion  of  both. 

It  follows,  naturally,  that  the  treatment  of  flexion  of  both  the 
body  and  cervix — i.  e.,  the  third  form  mentioned — should  include  the 
treatment  of  the  first  and  second  forms. 

The  treatment  of  flexion  is  as  follows:  When  the  vaginal  por- 
tion of  the  cervix  is  unusually  long  and  conical,  amputation  may  be 
called  for,  and  is  often  followed  by  very  satisfactory  results.  In  the 
majority  of  cases  a  less  important  operation  will  answer.  By  clip- 
ping out  a  Y-shaped  piece  in  each  lateral  edge  of  the  os,  and  extend- 
ing upward  from  an  eighth  to  a  fourth  of  an  inch,  a  few  of  the 
circular  fibers  are  divided.  This  permits  the  longitudinal  fibers  to 
contract,  and  thus  shortens  the  vaginal  portion  of  the  cervix. 

By  far  the  most  frequent  and  important  lesion  that  occurs  in  the 
connection  of  the  uterus  and  vagina  is  the  imperfect  invagination  of 
the  anterior  wall  of  the  cervix,  which  has  been  described  under  the 
head  of  pathology.  To  overcome  this  deformity,  I  have  adopted 
tlie  following  plan  of  treatment :  The  patient  is  placed  on  her  left 
side,  and  Sims's  speculum  is  introduced.  The  posterior  lip  of  tlie 
cervix  uteri  is  seized  with  a  tenaculum,  and  the  cervix  drawn  back- 
ward toward  the  hollow  of  the  sacrum.  This  puts  the  anterior 
column  of  the  vagina  on  the  stretch,  at  the  point  where  it  is  reflected 
on  the  cervix.  The  vaginal  wall  is  then  divided  transversely  with 
the  scissors,  about  three  fourths  of  an  inch  from  the  os  uteri,  the 
incision  being  from  a  quarter  to  three  eighths  of  an  inch  deep 
(Fig.  3T).  The  vaginal  wall  is  dissected  up,  so  that  when  the  incised 
jxjrtion  is  put  upon  the  stretch  the  sides  will  come  together.  In 
other  words,  the  upper  and  lower  edges  of  the  incised  central  por- 
tion of  the  vaginal  wall  are  drawn  apart,  and  the  sides  brought 
together  to  fiil  the  space,  so  that  the  transverse  incision  now  ap- 


6Q 


DISEASES   OF    WOMEN. 


peal's  as  a  longitudinal  one.     Three  or  four  sutures  are  introduced, 
to  keep  the  parts  together  till  they  unite  (Fig.  38). 


Uperatiou  lor  imijcrlcct  invagination.     The  incision. 


If  the  uterus  is  slightly  below  its  normal  level,  and  inclined  to 
retroversion  (a  condition  not  uncommon  in  antetiexion ),  much  benefit 
will  be  obtained  by  introducing  a  double-lever  pessary,  largest  at  its 
posterior  extremity.     This  will  hold  up  the  uterus,  and,  by  making 


^ 


Fig.  38. — Operation  for  imperfect  invagination.     Sutures  in  position. 

pressure  in  the  posterior  vaginal  cul-de-sa<\  draw  the  cervix  back- 
ward, and  thus  hold  the  edges  of  the  wound  together  and  favor 
union.  The  etfect  of  this  simple  and  safe  ojKMtition  is  to  bring 
the  anterior  wall  of  the  cervix  farther  down  into  the  vagina,  and 
permit  it  to  extend  backward  more  toward  the  axis  of  the  pel- 
vis, where  it  ought  to  be.  This  plan  of  treatment  I  have  found  to 
be  sufficient  for  the  relief  of  tlexion  of  the  cervix  uteri  in  many 
cases. 


FLEXIONS    OF   THE   UTERUS. 


67 


The  treatment  of  flexion  of  the  body  of  tlie  ntenis  requires  flrst 
that  the  organ  should  be  made  straight,  and  then  that  it  should 
be  kept  straight,  as  already  stated.    The  first  ob- 
ject can  be  accomplished  most  easily  by  the  use  U 
of  Elliott's  uterine  adjuster  (Fig.  39).      I  am  in-          ;  j 
debted  to  Dr.  T.  G.  Thomas  for  the  knowledge  \ 
of  the   method  of   using   this   instrument.      It  ' 
looks  like  a  uterine  bougie,  with  a  round  metallic 
disk  at  its  end.     By  turning  this  disk,  the  point 
of  the  instrument  can  be  bent  forward  or  back- 
ward at  the  will  of  the  operator.     In  using  it  to 
straighten  the  flexed   uterus  the   instrument  is 
canied  forward  and  passed  into  the  uterus ;  the 
disk  at  the  end  is  then  tui'ned  in  the  reverse  di- 
rection, and  the  instrument,  carrying  the  body 
of  the  uterus  with  it,  is  bent  in  the  opposite 
dii-ection   until   the   body  and   cervix   uteri  are 
brought  into   line  with  each  other.     There  are 
certain  precautions  necessary  in  using  this  instru- 
ment to  straighten  a  flexed  uterus,  but  these  will 
be  brought  out  in  the  history  of  cases  which  fol- 
low. 

In  straightening  the  uterus  with  Elliott's  ad- 
juster it  is  useful  to  bend  the  uterine  body  back- 
ward bej^ond  the  line  of  the  cervix  when  this  can 
be  done  without  causing  much  pain.  The  stretch- 
ing of  the  wall  of  the  uterus  at  the  point  of  flex- 
ion stimulates  nutrition  and  gives  strength  to  the 
weak  part.  By  repeating  this  treatment  many 
times,  much  relief  is  given,  and  much  progress 
made  toward  finally  overcoming  the  deformity. 

To  keep  the  uterus  straight  in  anteflexion  of 
the  body,  two  of  the  many  methods  commended 
I  have  found  useful — the  first  being  the  use  of 
an  anteflexion  pessary,  those  of  Thomas  (Figs.  40, 
41,  and  42)  and  Hewitt  (Fig.  43)  being  preferable.  These  mechan- 
ical supports  will  sometimes  answer  where  the  vagina  is  large  and 
relaxed,  conditions  not  often  found  in  flexion. 

The  other  means  is  the  intra-uterine  stem  with  a  vaginal  pessary 
to  keep  it  in  position — the  glass  or  hard-rubber  stem  and  vaginal 
pessary,  with  a  cup  devised  by  Thomas,  being  my  choice  (Fig.  44). 

In  using  the  intra-uterine  stem  the  greatest  possible  care  should 


Fig. 


39.— Elliott's 
ine  adjuster. 


uter- 


08 


DISEASES   OB^   WOMEN. 


be  employed  because  of  the  great  danger  of  exciting  inflammation. 
Before  resorting  to  the  use  of  this  instrument  all  congestion  and 


Fig.  40.  Fig.  41.  Fig.  12. 

Figs.  40-42. — Thomas's  anteflexion  pessary;  in  vagina,  in  position  ;  on  removal. 

irritabilitj  sliould  be  subdued,  as  far  as  possible,  and  the  uterus 
should  be  trained  to  tolerate  a  foreign  body  in  its  cavity.  The  lat- 
ter can  be  accomplished  by  the  careful  use  of  Elliott's  adjuster, 

which  should  be  em- 
ployed to  straight- 
en the  uterus  many 
times  before  using 
the  stem.  The  de- 
tails of  this  part  of 
the   treatment   will 


be  given  in  the  his- 
tory of  cases.  De- 
fects of  the  canal  of 
the  uterus  are  fre- 
quently associated 
with  flexion.  Some- 
times the  whole  ca- 
nal of  the  cervix  is 
too  narrow,  and 
again  thei-e  is  a  stric- 
ture at  the  internal 
OS.  To  overcome 
these  defects,  and  to 
aid  in  correcting 
the  flexion,  several 
methods  have  been  employed,  the  chief  among  them  being  incision 
and  dilatation.     When  the  constriction  is  at  the  internal  or  external 


Fig.  43. — Graily  Hewitt's  antcversion  pessary. 


FLEXIONS    OF  THE   UTERUS. 


69 


Fig.  44. — Stem  pessary  of  Thomas. 


Incision  and  dilatation  are 


OS,  or  botli,  I  prefer  incision  followed  by  the  use  of  the  intra-nterine 
stern,  or  the  frequent  passing  of  the  uterine  sounds  of  different  sizes. 
Where  the  whole  canal  is  contracted, 
I  ]>refer  dilatation.  This  may  be  easy 
and  gradual,  or  forcible.  The  first 
consists  in  passing  graduated  sounds, 
the  other  in  using  the  nterine  dilator 
(see  Fig.  16). 

I  prefer  the  forcible  dilatation 
when  there  are  no  contra-indications, 
such  as  extreme  sensitiveness ;  bnt  I 
do  not  approve  of  carrying  the  dila- 
tation beyond  that  which  is  snfficient 
to  admit  a  No.  10  or  12  English 
sound.  The  extreme  dilatation  prac- 
ticed by  some,  which  is  carried  to  a 
point  sufficient  to  admit  the  index- 
iinger,  is  dangerous  and  unnecessary, 
necessary  when  the  canal  is  undersized,  and  should  be  employed  only 
when  that  condition  exists.  Little  permanent  good  will  come  of  this 
treatment  except  as  preparatory  to  the  use  of  the  stem.  In  cases  of 
flexion  of  the  body  and  cervix  it  follows,  as  a  matter  of  course,  that 
all  the  means  given  above  for  the  treatment  of  each  must  be  em- 
ployed. 

Finally,  it  may  be  noted  that  success  in  the  treatment  of  flexions 
depends  upon  the  careful  use  of  the  means  suggested,  avoiding,  as 
far  as  possible,  the  ever-present  danger  of  exciting  inflammation, 
which  may  make  matters  far  worse.  And  much  depends  upon  the 
age  of  the  patient.  It  is  always  more  easy  to  correct  deformities 
in  the  young  than  in  those  of  more  advanced  life.  It  should  also  be 
borne  in  mind  that  there  is  a  tendency  for  the  flexion  and  all  con- 
sequent symptoms  to  return  unless  utero-gestation  foUows.  On  this 
account  I  have  classifled  the  results  of  my  treatment  in  married 
women  under  two  heads,  viz.,  relieved,  and  cured.  The  former  em- 
braces those  who  have  been  relieved  from  dysmenorrhoea,  but  have 
remained  sterile,  and  the  latter  those  who  have  been  relieved  and  have 
borne  children. 

ILLUSTRATIVE    CASES. 

Anteflexion  of  the  Cervix  Uteri,  Sims's  Operation.  (Relieved.) — 
This  patient  was  a  strong,  healthy  lady,  who  began  to  menstruate  at 
the  age  of  fourteen  years.  She  continued  in  good  health,  and  the 
menses  were  normal,  except  that  she  had  more  discomfort  than  be- 


70  DISEASES   OF   WOMEN. 

longs  to  perfect  liealtli.  About  the  age  of  eighteen,  menstruation 
became  more  painful,  and  she  had  some  backache  and  occassional 
leucorrlia?a.  These  symptoms  increased  but  little  until  she  was 
married,  at  twenty-two  years  of  age.  Then  she  began  to  have 
dvsmenorrluta,  and  occasional  menorrhagia.  The  leucorrha^a  and 
backache  became  more  persistent  and  her  strength  failed.  The 
pain  at  the  menstrual  period  was  not  very  severe ;  in  fact,  it  was 
not  at  all  like  the  violent  pain  often  present  in  flexion  of  the  body 
of  the  uferus,  but  it  made  her  life  quite  miserable  at  that  time. 
About  eighteen  months  after  her  marriage  she  tirst  applied  for 
treatment,  when  the  above  symptoms  were  related. 

The  OS  externum  pointed  toward  the  vulva,  and  the  vaginal  por- 
tion of  the  cervix  was  slightly  flattened  from  below  upward.  The 
invagination  of  the  cervix  anteriorly  was  nearly  normal,  but  not  in 
proportion  to  that  of  the  posterior  wall,  which  appeared  to  be  ex- 
cessive. The  body  of  the  uterus  was  in  its  normal  position  ;  the 
sound  could  not  be  passed  until  the  cervix  was  dragged  backward 
and  brought  in  a  line  with  the  body. 

She  was  treated  for  a  time  to  relieve  her  congestion  and  cervical 
endometritis,  and  then  the  posterior  wall  of  the  cervix  was  divided 
according  to  Sims's  method.  When  the  edges  of  the  wound  healed, 
there  was  considerable  inversion  of  the  mucous  membrane,  showing 
that  it  was  redundant.  The  protruding  portions  were  trimmed  off, 
and  then  the  results  of  the  operation  were  quite  satisfactory  in  ap- 
pearance. She  was  relieved  of  all  her  symptoms,  for  a  time  at 
least,  but  remained  sterile,  although  the  canal  was  large  enough,  and 
the  sound  could  be  passed.  Three  years  afterward  she  was  seen, 
and  then  she  was  complaining  of  leucorrhrea  and  occasional  pelvic 
pains. 

This  case  was  treated  eight  years  ago,  and  is  the  last  one  in 
which  1  have  performed  Sims's  operation  for  flexion. 

Extreme  Anteflexion  of  the  Cervix  Uteri;  DysmenorrhcEa.  (Re- 
covery.)— The  patient  was  first  seen  at  the  age  of  twenty-five.  Her 
past  history  was  tliat  of  good  health.  Menstruation  occurred  first  at 
fifteen,  and  from  that  time  onward  was  normal,  except  that  it  was 
accompanied  with  pain.  During  the  first  few  years  after  puberty 
the  pain  was  slight,  but  it  gradually  increased  until  it  was  suffi- 
ciently severe  to  unfit  her  for  everything  during  the  menstrual 
period.  Her  general  health  began  to  fail ;  she  lost  flesh,  and  became 
very  nervous  and  irritable,  and  it  was  on  this  account  that  she  sought 
relief. 

I  found  that  the  anterior  wall  of  the  cervix  uteri  was  on  a  line 


FLEXIONS   OF   THE   UTERUS.  Yl 

with  the  anterior  wall  of  the  vagina,  and  the  os  pointed  toward 
the  pubes.  The  posterior  wall  of  the  cervix  projected  into  the  va- 
gina far  more  than  nornial ;  in  fact,  the  cervix  was 
hooked  upward.  The  body  and  fundus  were  in  the 
normal  position. 

Fig,  45  \^nll  give  an  idea  of  this  form  of  flex- 
ion. It  gave  the  impression  that  in  the  descent  of 
the  uterus  the  antenor  wall  of  the  cervix  had  been 
arrested  in  its  progress  by  the  vaginal  wall,  while 
the  posterior  wall  of  the  uterus  descended  beyond  ^^^^I'g^^-^^^^'^^ 
the  normal  extent.  It  was  very  difficult  to  pass  the 
sound;  to  do  so,  the  uterus  had  to  be  raised  up  in  the  pelvis  and 
partially  retro  verted.  Drawing  the  cervix  forcibly  backward  toward 
the  sacrum  developed  a  band  of  the  anterior  wall,  which  ran  from 
the  extreme  end  of  the  cervix  upward  and  forward  about  an  inch 
and  a  half,  and  there  blended  \vith  the  vaginal  wall.  It  was  easily 
seen  that  this  abnormal  attachment  of  the  vagina  was  the  cause  of 
the  flexion  of  the  cervix. 

Preparatory  treatment  was  employed  for  a  short  time,  to  reduce 
congestion,  and  then  the  operation,  already  described,  to  correct  the 
invagination  of  the  cervix,  was  performed.  The  ridge  of  anterior 
vaginal  wall  was  divided  a  little  less  than  an  inch  from  the  cervix, 
and  then  very  gentle  traction  was  suflicient  to  draw  the  cervix  back 
into  its  proper  relations  with  the  body  of  the  uterus.  The  wound, 
which  was  made  at  right  angles  to  the  axis  of  the  vagina,  became 
parallel  to  it,  when  the  cervix  was  carried  back  into  its  normal  po- 
sition. It  was  closed  with  silk  sutures,  carried  deep  down  into  the 
wall  of  the  vagina,  to  make  sure  that  the  deeper  portions  of  the 
wound  were  coaptated.  When  the  sutures  were  tied,  the  invagina- 
tion was  seen  to  be  complete,  and  the  cervix  was  carried  well  back, 
quite  as  far  as  it  should  be ;  there  was  also  a  noticeable  traction 
on  the  sutures,  because  the  cervix  inclined  to  flex  forward  again. 
To  correct  this,  a  stem-pessary  was  introduced,  which  extended  al)Out 
half-way  up  the  cavity  of  the  body  of  the  uterus.  This  was  held  in 
position  at  first  with  a  marine  lint  tampon,  and  when  the  wound 
healed  the  stem  was  held  in  j)lac?e  by  the  retaining  pessary.  The 
operation  was  done  without  ether,  and  the  patient  did  not  com- 
plain of  pain,  except  when  the  stem  was  introduced  into  the  uterus. 

Ten  days  after  the  operation  the  sutures  were  removed  and  the 
union  M'as  complete  ;  the  stem  was  still  left  in  place.  After  another 
week  had  gone,  there  was  considerable  congestion  in  the  canal,  indi- 
cated by  a  free  discharge.     The  stem  was  removed,  and  an  applica- 


72  DISEASES  OF   WOMEN. 

tion  of  t:inuin  and  ijlycurin  made.  After  the  sutures  were  removed, 
the  douche  of  l)ora\'  and  warm  water  was  used  daily,  and  once  a 
week  the  stem  was  removed  and  the  canal  jxiinted  with  tannin  and 
glycerin.  The  next  menstrual  period  was  without  the  severe  piiin 
which  she  suffered  l)efore  the  treatment.  Still  there  were  backache 
and  pelvic  tenesmus.  The  stem  was  left  in  place  during  menstrua- 
tion and  for  three  weeks  after,  but  during  that  time  it  was  removed 
every  week,  and  the  application  of  tannin  made. 

The  second  menstruation  after  the  operation,  the  first  after  the 
removal  of  the  stem,  was  painless.  Subsequently  there  was  no  re- 
currence of  the  flexion,  and  her  menstruation  has  continued  regu- 
lar and  ^^'ithout  pain.  It  is  now  three  years  since  she  was  treated, 
and  she  remains  well  and  free  from  dysmenorrhoea. 

I  may  add  here,  that  in  all  cases  of  anteflexion  of  the  cervix,  due 
to  imperfect  vagination,  the  treatment  given  above  has  been  suc- 
cessful. 

Anteflexion  of  the  Body  and  Cervix  Uteri  with  Prolapsus.  (Recov- 
ery.)— This  patient  was  a  little  below  the  medium  size,  but  was 
strong  and  active.  She  began  to  menstruate  at  thirteen,  and  con- 
tinued to  do  so  rather  irregularly.  She  generally  went  over  time  a 
varying  number  of  days.  From  the  first,  menstruation  was  painful, 
the  pain  gradually  increasing  from  month  to  month  and  year  to  year. 
This  pain  was  chai*acteristic  of  flexion  ;  it  began  before  the  flow 
was  relieved,  diminished  when  the  flow  was  well  established,  and 
subsided  entirely  on  the  second  day.  The  pain  was  referred  to  the 
uterus,  and  was  intermittent.  From  puberty  to  al)Out  twenty-one 
years  of  age  her  health  was  j^erfect  between  the  menstnial  periods. 
She  then  began  to  sufter  from  backache,  leucorrhopa,  occasional  ova- 
rian pain,  and  gradually  her  digestion  became  impaired,  and  the 
nervous  system  fretted. 

She  was  first  seen  at  the  age  of  twenty-four,  when  the  above 
history  was  obtained.  It  was  evident  that  all  her  symptoms  were 
increasing  in  severity ;  general  congestion  and  tenderness  of  the 
vagina,  uterus,  and  ovaries,  were  found  at  the  examination.  The 
OS  externum  pointed  toward  the  vulva,  and  the  fundus  could  be  felt 
through  the  anterior  wall  of  the  vagina.  The  cervix  was  normal  in 
size,  and  projected  into  the  vagina  in  due  proportions,  anteriorly  and 
posteriorly.  The  uterus  rested  low  down  in  the  pelvis,  and  the  cer- 
vix appeared  to  be  bent  forward  by  the  pressure  u]>on  the  pelvic  floor. 
These  signs,  obtained  by  touch,  were  all  confirmed  by  the  sound 
and  speculum.  The  sound  was  passed  through  the  os  internum  with 
difficulty  at  first.     There  was  no  change  in  the  stnictures  of  the 


FLEXIONS  OF  THE  UTERUS.  Y3 

litems  except  tlie  flexion  ;  tlie  con2;estion  was  well  marked,  and  there 
was  slight  leucorrhd^a,  indicating  that  cervical  endometritis  was 
being  developed. 

The  treatment  of  this  patient  consisted  in  remedies  to  improve 
digestion.  Bromide  of  sodium  was  given  to  qniet  her  nervous  sys- 
tem. Locally,  the  hot- water  douche  was  em]:)loyed  ;  the  os  exter- 
num was  dilated,  and  tincture  of  iodine  applied  to  the  cervical 
canal ;  the  uterus  was  raised  to  its  proper  elevation,  and  held  there 
at  tirst  with  a  tampon,  and  afterward  with  a  small  Peaslee's  pessary. 
The  following  week  the  internal  os  was  dilated,  until  it  admitted 
a  No.  10  sound,  and  the  iodine  was  also  repeated.  This  caused  much 
pain,  and  compelled  the  patient  to  rest  in  bed  a  few  days,  during 
which  time  the  hot  douche  was  continued.  After  this,  the  uterus 
was  made  straight  by  using  Elliott's  adjuster  once  a  week.  The 
douche  and  iodine  were  continued,  and  this  completed  the  plan  of 
treatment. 

For  six  months  this  course  of  local  treatment  was  followed  out, 
the  constitutional  treatment  being  varied  as  the  symptoms  changed. 
The  tenderness  and  congestion  first  disappeared,  and  the  pain  dur- 
ing menstruation  gradually  became  less  and  less,  and  finally  ceased 
entirely. 

The  patient  remained  under  observation  tw^o  months  longer,  and 
then  married,  and  seven  months  later  her  physician  reported  to  me 
that  she  was  four  months  pregnant. 

Anteflexion  of  the  Body  of  the  Uterus ;  Stenosis  at  the  Os  Inter- 
num, treated  with  Stem-Pessary.  (Recovery.) — This  patient  had  good 
health,  but  was  of  a  highly  nervous  temperament,  a  condition  which 
had  been  increased  by  a  severe  and  prolonged  education.  She  be- 
gan to  menstruate  at  fifteen,  and  had  dysmenorrhea  from  the 
beginning.  She  managed  to  get  along  by  resting  at  the  menstrual 
periods,  and  bearing  her  suffering  as  best  she  could,  but  at  the  age 
of  twenty-eight  gave  up,  and  sought  advice.  Her  general  health 
at  that  time  was  impaired,  and  she  was  quite  despondent.  When 
first  examined,  the  usual  signs  of  anteflexion  of  the  body  of  the 
uterus  were  found.  The  cervix  was  also  slightly  bent  forward. 
The  canal  of  the  uterus  was  of  full  size,  except,  at  the  internal  os; 
a  small  probe  only  could  be  passed  at  that  point.  The  uterus  was 
quite  tender,  and  there  was  some  catarrh  of  the  cervical  mucous 
membrane.  Tonic  and  sedative  treatment  was  begun,  and  the  strict- 
ure was  incised  on  two  sides,  with  the  hysterotome. 

After  this,  a  sound  was  passed  twice  a  week  for  a  time.  The  pa- 
tient was  much  relieved  by  this  treatment,  but  still  suffered  pain  at 


DISEASES   OF   WOMEN. 


the  niL'Uijtraul  periuds.     The  i)ain   returned  tu  a  certain   extent,  at 
each  menstruation,  and  at  the  end  of  a  year  treatment  had  to  be  re- 


Fio.  46  — Skene's  sound  and  scarificator. 

newed.  At  that  time  the  patient  appeared  to  l)e  as  badly  off  as 
when  first  seen.  Dilatation  of  the  canal  and  straightening  the  uterus 
with  Elliott's  adjuster  gave  some  relief.  More  tliorough  treatment 
was  advised,  but  she  would  not  consent  to  give  her  whole  time  to  it. 

Four  years  later  the  patient  returned  in  nmch  worse  condition 
than  when  first  treated.  The  tissues  of  the  uterus  were  much  liard- 
er,  and  there  was  more  tenderness.  Great  pain  was  experienced  upon 
passing  the  sound,  and  any  effort  to  straighten  the  uterus  was  un- 
bearable. Sleeplessness  was  now  a  prominent  symptom,  and  she 
was  obliged  to  take  morphine  at  the  menstrual  periods. 

I  prescribed  the  rest-treatment,  Avith  tonics,  bromides,  massage, 
and  the  hot-water  douclie,  and  the  application  of  tincture  of  iodine 
to  the  cervix  uteri  and  the  upper  part  of  the  vagina.  When  the 
general  health  had  been  improved 'by  two  months  of  this  treatment, 
the  cervical  canal  was  dilated,  under  the  use  of  cocaine,  until  it  ad- 
mitted a  No.  12  sound.  The  uterus  was  then  straightened  with  the 
Elliott  adjuster,  and  a  glass  stem-pessary  introduced.  Although  she 
was  kept  quiet  after  the  introduction  of  the  stem,  the  suffering  was 
so  great  that  at  the  end  of  two  hours  it  had  to  be  removed.  The 
general  treatment  was  resumed  for  about  four  days,  and  the  stem 
was  again  used ;  this  time  it  was  worn  for  five  days,  but  had  to  be 
again  removed,  owing  to  the  pain  it  caused.  The  irritation  was 
again  subdued  by  the  hot  douche  and  cocaine  applied  to  the  canal  of 
the  cervix,  and  occasionally  an  application  of  iodine  and  carbolic  acid 
was  made.  A  week  later  the  stem  was  used  again ;  it  then  caused 
less  pain,  but  she  had  to  remain  in  bed,  and  there  was  still  consid- 
erable distress.  There  was  also  a  marked  leucorrh(i?al  discharge.  It 
was  necessary  to  remove  the  instrument  about  every  five  days,  and 
treat  the  cervical  endometritis. 

Three  weeks  passed  before  the  patient  could  be  trusted  to  walk 
around,  and  it  was  two  months  longer  before  she  could  walk  out  and 


FLEXIONS   OF  THE   UTERUS.  75 

ride  without  causing  pain.  Tlie  dysnuinon-lifjea  was  less  severe  each 
mouth,  and  finally  subsided  entirely.  The  stem  was  worn  altogether 
about  four  months ;  during  all  that  time  the  case  had  to  be  watched 
and  treated  for  a  recnrring  endometritis,  but  finally  the  recovery  was 
complete. 

Two  years  have  passed  since  the  treatment  was  completed,  and 
the  patient  remains  well.  The  chances  are,  however,  that  the  flexion 
will  recur. 

It  will  be  noticed  that  the  stem  caused  much  irritation,  and  re- 
quired constant  watching.  This  I  find  is  the  case  very  often.  There 
are  few  patients  who  will  tolerate  the  stem  unless  great  care  is  tak- 
en, and  they  are  treated  the  moment  that  symptoms  appear.  The 
longer  the  trouble  has  existed,  the  more  difficult  it  is  to  use  the 
stem.  The  uterus  becomes  more  dense  in  structure  and  more  sensi- 
tive in  old  cases,  and  the  results  of  treatment  are  not  very  satisfac- 
tory. This  is  the  rule,  and  there  are  not  many  exceptions  to  it. 
The  patient  whose  case  I  have  jnst  described  is  one  of  the  oldest 
that  I  have  ever  successfully  treated  for  flexion. 

All  the  cases  here  given  are  intended  to  show  the  different  forms 
of  flexion,  and  the  various  methods  of  treatment  employed.  It  will 
be  seen  that  my  object  is  not  to  use  one  method  of  treatment  in  all 
forms,  but  to  adapt  the  treatment  to  the  peculiar  requirements  of 
each  case. 

Finally,  I  may  add  that  I  have  succeeded  in  relieving  all  cases 
of  flexion,  of  whatever  form  or  degree,  temporarily  at  least,  by  the 
treatment  described,  excepting  when  there  were  complications,  such 
as  ovarian  disease,  or  the  results  of  old  inflammations.  A  consider- 
able number  have  entirely  recovered,  and  borne  childi'eUo 


CHAPTEE  Y. 

DISEASES   OF   THE    EXTERNAL    ORGANS    OF    GENERATION. 
ANATOMY. 

The  Pudendum. — The  pudeudum  comprises  all  those  parts  that 
are  situated  at  the  outer  and  lower  portion  of  the  pelvis.  It  is 
hounded  above  by  the  lower  part  of  the  abdomen,  on  either  side 
by  the  thigh*,  and  below  by  the  perin?eum.  In  general  outline  it  is 
wedge-shaped,  the  edge  being  do\\Tiward. 

The  several  parts  are  the  mons  veneris,  the  labia  majora  and 
minora,  the  clitoris,  and  the  hymen. 

The  mons  veneris  is  a  mass  of  tissue  which  covers  the  sym- 
physis pubis,  and  occupies  the  triangular  space  formed  by  the  junc- 
tion of  the  abdomen  and  thighs ;  it  is  composed  of  fatty  tissue  and 
rather  thick  integument,  which,  after  puberty,  is  covered  with  hair. 
At  its  lower  border  it  is  divided  into  two  folds  by  the  upper  por- 
tion of  the  urogenital  fissure.  The  labia  majora  are  two  j^rominent 
rounded  folds  of  integument,  continuous  above  with  the  mons  vene- 
ris, which  extend  downward  to  the  perinreum.  They  are  fonned 
by  integument  covered  with  hair  on  the  outer  side ;  the  inner  sur- 
face is  more  like  mucous  membrane  in  general  appearance,  but  it 
contains  sebaceous  glands  instead  of  mucous  folliclcp.  The  tissues 
of  the  lal)ia  beneath  the  skin  are,  connective  tissue,  elastic  elements, 
and  fatty  lobules  with  undei-lying  adipose  structure.  The  vascular 
supply  is  abundant,  forming  a  venous  plexus. 

The  labia  minora,  also  called  the  nymphn?,  are  two  small  folds  of 
mucous  membrane,  situated  upon  the  inner  sides  of  the  labia  majora, 
and  extending  downward  until  they  meet  posteriorly,  and  form  the 
thin  circular  band,  the  fourchette  or  fnenulum  vulva\  which  extends 
across  at  the  posterior  part  of  the  opening  of  the  vagina  outside  of 
the  hymen.  The  outer  surfaces  of  the  labia  minora  are  continuous 
with  the  labia  majora,  and  tlie  inner  surfaces  with  the  mucous  mem- 
brane of  the  vestibule. 


DISEASES   OF   THE   EXTERNAL   ORGANS   OF   GENERATION.     77 

The  clitoris  is  analogous  to  the  penis,  but  possesses  neither  cor])U8 
siiono-iosum  nor  urethra ;  it  is  erectile  in  structure,  and  is  described 
as  having  three  i)ai'ts— the  crura,  corpus,  and  glans.     The  crura  are 


'<•'«  ■F;,cR.cr   V.,-: 

Fig.  47. — Tlie  external  genitals  of  a  «oiiiau  who  has  lioiiie  children. 

oblong,  spindle-shaped  processes,  formed  by  the  bifurcation  of  the 
corpus ;  they  are  attached  to  the  rami  of  the  ischium  and  pubes.  The 
corpus  is  located  in  the  median  line  beneath  the  pubic  arch,  and 
terminates  anteriorly  in  a  rounded  extremity,  the  glans. 

The  relations  of  the  clitoris  and  the  labia  minora  are  as  follows : 
Each  labium  divides  anteriorly  into  two  folds,  which  surround 
the  glans  clitoridis,  the  superior  folds  meeting  to  form  the  preputium 
clitoridis  ;  the  inferior  folds' being  attached  to  the  glans,  and  forming 
the  fnenum. 

The  vestibule  is  the  triangular,  smooth  surface,  bounded  above 
by  the  clitoris,  on  either  side  by  the  nymphae,  and  below  by  the  an- 


78  DISEASES  OF   WOMEN. 

terior  vaginal  wall.  Just  above  tlu;  junction  of  the  vestibule  and 
vagina  the  meatus  urinarius  is  situated.  It  is  distinguished  by  its 
prujectirtn  beyond  the  general  surface  of  tlie  vestibule.  The  hymen 
is  a  thin  semi-lunar  fold  covered  on  both  external  and  internal  sur- 
faces with  mucous  membrane,  and  stretches  across  the  posterior  part 
of  the  orifice  of  the  vagina.  It  is  a  continuation  of  the  vagina 
(Budin).  In  fact,  the  h}Tiien  covers  the  orifice  of  the  vagina,  closing 
it  completely,  except  a  small,  crescentic  opening  just  behjw  the  mea- 
tus urinarius.  It  varies  in  different  subjects  in  regard  to  its  shape, 
hence  the  above  description  can  only  be  taken  as  that  of  the  typical 
form — the  deviations  from  this  type  will  be  referred  to  in  connec- 
tion with  the  pathological  conditions  of  the  hymen. 

The  meatus  urinarius  is  situated  in  the  median  line,  at  the  June, 
tion  of  the  lower  margin  of  .the  vestibule  and  the  margin  of  the  an- 
terior wall,  about  three  quarters  of  an  inch  below  the  clitoris.  It  is 
kept  closed  by  the  muscular  tissue  of  tlie  urethra,  and  presents  a 
puckered  appearance  and  projects  slightly  beyond  the  general  plane 
of  the  vestibule. 

The  line  of  junction  between  skin  and  mucous  membrane  runs 
along  the  base  of  the  inner  aspect  of  the  labium  majus,  passes  down 
beside  the  base  of  the  outer  aspect  of  the  hymen,  and  through  the 
fossa  navicularis. 

The  deeper  structures  of  the  external  parts  of  generation  are 
mostly  glands  and  blood-vessels  with  connective  tissue — the  arrange- 
ment of  the  two  latter  giving  the  characteristics  of  erectile  tissue. 

The  glands  are  of  two  kinds,  the  sebaceous  and  nuicous.  The 
sebaceous  glands  are  abundant  in  the  tissues  of  the  nymphiv ;  they 
furnish  a  yellowish-white  secretion,  which  has  a  ]ieculiar  odor.  In 
those  who  are  not  quite  cleanly  in  their  habits  this  secretion  accumu- 
lates beneath  the  upper  folds  of  the  nymphie,  around  the  glans  cli- 
toridis. 

The  mucous  glands  are  of  two  varieties — the  glandulte  vestibu- 
lares  majores  and  the  glandule  vestibulares  minorcs. 

The  glandulte  vestibulares  ininores  are  about  six  in  number,  and 
are  situated  about  the  meatus  urinarius ;  they  are  of  the  com}X)und 
racemose  variety,  and  have  short  ducts  with  large  orifices.  Some- 
times one  or  more  of  these  ducts  is  found,  much  eidarged,  and  look- 
ing like  a  cul-de-sac,  large  enough  to  admit  the  point  of  a  small 
catheter. 

The  glandulpe  vestibulares  majores  are  two  in  number  and  al>out 
the  size  of  a  pea,  and  are  of  a  reddish-yellow  color.  They  are  situ- 
ated at  the  ])Osterior  extremity  of  the  bulbi  vestibuli,  and  are  jiar- 


DISEASES   OF   THE  EXTERNAL   ORGANS  OF  GENERATION.     79 

tially  included  in  the  bnlbi,  or,  more  properly  speaking,  the  glands 
and  the  biilbi  overlap  each  other. 

They,  like  the  glandultie  minores,  are  of  the  compound  racemose 
variety,  and  their  acini  open  into  a  duct,  more  than  half  an  inch  in 
length,  which  is  wide  where  it  leaves  the  gland,  but  b(3Comes  nar- 


I'lG.  4P.— The  superticiiil  veins  of  the  pcrinanim  (Savage) :  /<,.r/,  crura  clitoriclis  ;  c,  cor- 
pus clitoridis;  1,  2,  3,  corpus  cavernosum  urcthrte ;  5,  superior  perineal  and  obtura- 
tor veins  ;  6,  veins  of  communication  with  superior  epigastric  veins;  8,  9,  10,  pudic 
vein  and  primary  branches  ;  d,  tuberosity  of  ischium  ;  o,  coccyx  ;  6',  vulvo-vairinal 
gland;  «,  anterior  border  of  gluteus  maximus  muscle;  B,  superficial  sphincter'and 
muscle  ;  (j,  erector  clitoridis  muscle  ;  h,  left  crus  clitoridis. 

rower  toward  its  orifice.  These  ducts,  in  their  com-se,  ran  along  the 
nnier  side  of  the  vaginal  bulbs,  and  terminate  in  front  of  the  hymen, 
about  midway  from  the  base  of  the  vestibule  and  the  posterior  border 
of  the  hymen,  or  its  remains. 


80 


DISEASES   OF    WuMEN. 


Tlie  remaining  deeper  structures  of  the  pudendum  of  special  in- 
terest are  cellular  tissue  and  two  masses  of  i)loi>d-ve.-sels,  known  as 
the  hull)i  vestihuli  vagina*.  These  bulbs  of  the  vaginal  vestibule 
are,  when  distended  with  blood,  about  an  inch  long;  they  are  located 
on  each  side  between  the  vestibule  and  the  pubic  arch.  They  are 
composed  of  reticulated  veins  and  erectile  tissue.  The  upper  ends 
of  these  bulbs  are  pointed,  and  communicate,  by  an  intervening 
small  plexus,  the  pars  inteiTQcdia,  with  the  vessels  of  the  glans  cli- 
toridis  (^Fig.  48). 

The  oriUcium  vaginae  differs  greatly  in  size  and  general  appear- 


if:St£t^.a&2^^4^'?^^r>^ii;'::'^ 


^^"^frrin 


biG.  4'.t. — Kxtcriial  L^uniiais  ol  vir^'iii. 


ance  in  the  virgin,  in  those  accustomed  to  sexual  intercourse,  and  in 
those  who  have  borne  children  (see  Figs.  49  and  47j. 


DISEASES   OF  THE   EXTERNAL   ORGANS   OF   GENERATION.     81 

In  virgins  the  hymen  is  present,  as  a  rule,  and  its  upper  crescen- 
tic  border,  with  its  concavity  looking  toward  the  urethral  opening, 
forms  the  vaginal  orifice.  There  is  a  considerable  variation  in  the 
shape  of  the  hymen,  and,  though  there  are  deviations  from  the  nor- 
mal type,  they  are  not  of  necessity  morbid  states,  but  rather  jk-cuI- 
iarities  of  formation.  The  most  common  of  these  are  the  liymen 
cribriformis  (Fig.  50),  which  has  a  nmnber  of  small  openings ;  the 


Fig.  5n.-Cribriform  hymen.    Fig.  51.-Annular  hymen  (j).        Fig.  52.-Fimbriate  hymen 

hymen  annularis  (Fig.  51),  which  has  one  small  central  opening ; 
the  hymen  fimbriatus  (Fig.  52),  so  called  because  it  is  fringed  some- 
what like  the  extremity  of  a  Fallopian  tube. 

^  The  hymen  is  usually  lacerated  in  several  places  during  the  first 
coitus,  but  of  some  instances  this  does  not  take  place.  Cases  have 
been  seen  in  mar-ried  women  in  whom  the  hymen  is  very  elastic  and 
distensible.  Hyrtl  mentions  one  specimen,  in  the  museum  at  Halle, 
where  the  hymen  is  perfect,  though  the  woman 
had  given  birth  to  a  seven  monthb'  child.  The 
cai-uncuhB  myrtiformes  are  a  number  of  isolated 
elevations  of  mucous  tissue  about  the  orifice  of 
the  vagina,  whicli  most  authors  claim  to  be  the 
remains  of  the  lacerated  hymen.     Schroeder  has  a: 

])onited  out  that  these  elevations  or  canmculfe  Fig.  53.  —  R,  rteetum, 
are  ])roduced  by  child-bearing,  and  not  bv  simjDle 
laceration  of  the  hymen.     Clinical  observations 
coidirm  tlie  view^s  of  Schroeder. 

Development  and  Malformations  of  the  Vulva. 
—During  the  second  month  of  fetal  life  the  rec- 
tum, allantois,  and  Miiller's  ducts  communicate,  but  there  is  as  yet 
no  openmg  of  these  to  the  exterior  (Fig.  53). 


continuous  with  All, 
allantois  (bladder)  and 
M  duct  of  Miiller  (va- 
gina) ;  z,  depression 
of  skin  which  grows 
inward  and  forms  the 
vulva  (Schroeder). 


82 


DISEASES   OF   WOMEN. 


Fig.  54. — Tlie  depression 
has  extended  inward 
and  become  continuous 
with  the  rectum  and 
allantois  forming  the 
cloaca  {CI). 


Fig.  Tjo. — The  cloaca  is 
dividing  into  urogen- 
ital sinus  (Su)  and 
anus  by  downward 
growtli  of  perineal 
septum. 


Later  on,  about  the  tenth  week,  the  genital  cleft  forms;  this  is  a 
depression  in  the  skin  which  gradually  e.xtends  deeper  and  deeper 

until  it  connnunicates  with 
the  allantois  and  the  rectum, 
and  becomes  the  cloaca 
(Fig.  54). 

The  structure  which  lies 
between  the  rectum  and  the 
allantois  grows  in  a  down- 
ward direction,  dividing  the 
cloaca  into  two  parts ;  that 
which  is  situated  anteriorly 
is  the  urogenital  sinus  into  which  Miiller's  ducts  open  ;  the  posterior 
part  becomes  the  anus,  while  the  lower  end  of  this  downward  growth 
forms  the  perinaeum  (Fig.  55). 

The  upper  portion  of  the  urogenital  sinus,  becoming  more  and 
more  coutractel,  forms  tlie  urethra,  the  lower  part  remaining  as  the 
vestil)ule  (Figs.  56 
and  57). 

As  has  elsewhere 
been  stated,  the 
ducts  of  Miiller  unite 
to  form  the  vagi- 
na. The  clitoris  is 
formed  from  the 
genital  eminence, 
and  the  labia  minora  from  the  edg^es  of  the  .<jenital  cleft. 

From  this  brief  consideration  of  the  manner  of  formation  and 
development  of  the  external  genital  organs,  their  malformations  are 
the  more  readily  understood.  Thus,  if  the  depression  which  is 
known  as  the  genital  cleft  fails  to  be  formed,  complete  atresia  of  the 
vulva  results.  If  the  partition  between  the  rectum  and  vagina  is  not 
developed,  the  condition  known  as  atresia  of  the  anus  results.  From 
the  description  already  given,  it  will  be  seen  that  this  is  nothing  more 
than  the  continuance  of  the  cloaca.  In  other  cases  the  urethra  fails 
to  be  developed,  and  there  is  then  a  persistence  of  the  urogenital 
sinus,  or  what  is  commonly  known  as  hypospadias. 

Hermaphroditism. — In  hermaphroditism  both  ovaries  and  testi- 
cles, or  one  ot  each,  exist  in  the  same  individual ;  these  cases  are 
extremely  rare,  though  they  have  been  observed  and  described  by 
Ilildebrandt,  Bannon,  and  others.  In  false  or  pseudo-herniaphro- 
ditism  a  condition  exists  in  which  the  external  genitals  appear  to 


Fig.  56. — The  perineal  body 
is  completely  formed 
(Schroeder). 


Fig.  57. — The  upper  part  of 
the  urogenital  ninus  ha~ 
contracted  into  the  urethra: 
the  lower  portion  persists 
as  the  vestibule  (.*»«), 
(Schroeder). 


DISEASES   OF   THE   EXTERNAL   ORGANS   OF   GENERATION.     83 


belono-  to  the  opposite  sex.  Thus,  the  clitoris  may  be  so  hypertro- 
pliied  as  to  resemble  a  penis,  and  the  labia  minora  be  so  closely  in 
a  p [position  as  to  be  mistaken  for  a  scrotum  ;  or,  on  the  other  hand, 
tiie  individual  may  be  in  reality  a  male,  in  whom  the  condition  of 
hypospadias  may  exist,  and  thus  the  appearances  seem  to  indicate  a 
female.  A  case  is  reported  by  Otto,  in  which  the  external  genitals 
of  the  individual  so  resembled  those  of  a  female  that  he  lived  as  the 
wife  of  three  husbands  without 
the  fact  that  he  was  a  male  being 
discovered ;  and  then  the  mys- 
tery was  only  solved  by  medical 
examination.  Fig.  58  represents 
the  appearance  of  the  organs  in 
this  remarkable  case.  In  these 
cases  of  false  hermaphroditism 
careful  examination  will  settle 
any  doubts  which  may  have  aris- 
en. The  parts  simulating  both 
scrotum  and  labia,  when  exam- 
ined, will,  if  the  individnal  is  a 
male,  contain  the  testicles  ;  and, 
if  a  female,  no  such  body  will  be 
found. 

It  is,  of  course,  to  be  borne 
in  mind,  that  owing  to  the  non- 
descent  of  the  testicle,  no  body 
might  be  found,  and  still  the 
individual  be  a  male,  and,  on  the 
other  hand,  that  a  prolapsed 
ovary  might  be  mistaken  for  a 
testicle.  A  digital  examination 
should  also  be  made  through  the 
rectum  for  the  uterus  and  ovaries.  If  the  age  of  puberty  has  ar- 
rived, the  presence  or  absence  of  menstruation  will  be  a  valuable 
diagnostic  sign,  and  great  aid  may  be  derived  from  a  study  of  the 
other  portions  of  the  body,  as  the  breasts  and  the  face,  in  order  to 
detect  the  beginning  beard,  or  the  voice,  to  distinguish  its  tones.  It 
is,  of  course,  very  important  to  make  a  correct  diagnosis ;  but  when 
this  is  done,  the  physician's  duty  is  at  an  end,  so  far  as  being  of 
any  service  to  the  patient. 


Tig. 


58. — Spurious  hermaphroditism  (Simp- 
son), case  of  hypospadias  in  tlie  male 
making  the  external  organs  simulate 
those  of  the  female  :  a,  a,  lobes  of  scro- 
tum ;  n,  imperforate  penis,  Ij  inch  long; 
E,  perineal  fissure,  14-  inch  deep,  lined 
with  mucous  membrane,  at  bottom  of 
which  the  urethral  oriKce,  D,  is  seen ;  c, 
the  split  urethra  with  openings,  r,  of 
glands  beside  it. 


84  DISEASES  OF  WOMEN. 

DISEASES    OF    THE    PUDENDUM. 

Vulvitis. — Priiuaiy  inllaminatioii  of  the  vulva  is  quite  rare,  if 
the  specific  form  aud  the  vulvitis  of  children  are  excluded.  lu 
nearly  all  the  cases  that  have  come  under  my  observation  the  inflam- 
mation of  the  \'Tilva  has  been  secondary  to  and  caused  by  some  pre- 
existing affection.  When  it  is  due  to  gonorrhoea,  syphilis,  cancer  of 
the  uterus,  or  vaginitis,  it  must  necessarily  be  treated  as  a  complica- 
tion of  these  diseases,  rather  than  as  an  affection  in  and  of  itself. 

Uncomplicated  vulvitis  may  occur  in  several  forms — as  a  sim- 
ple erythema,  a  purulent  inflammation,  or  as  a  follicular  inflam- 
mation. 

The  erythematous  variety  is  characterized  by  a  general  redness  of 
the  vulva,  limited  to  the  mucous  surfaces,  though  sometimes  it  ex- 
tends to  the  skin.  It  is  usually  transient,  passing  away  without  much 
treatment. 

The  purulent  form  is  more  defined.  The  parts  are  red,  and  cov- 
ered with  a  copious  formation  of  pus.  The  epithelium  rapidly  ex- 
foliates, leaving  a  raw-looking  surface.  Occasionally  only  small 
patches  of  ulceration  are  to  be  seen,  but  these  are  neither  large  nor 
are  they  deep,  as  a  rule. 

In  follicular  vulvitis  the  mucous  membrane  generally  is  not  much 
changed  in  appearance ;  sometimes  it  has  a  deeper  color,  but  the 
whole  surface  is  studded  with  small,  red  points,  which  on  close  in- 
vestigation are  found  to  be  the  orifices  of  mucous  follicles.  The 
size  and  number  of  these  inflamed  spots  vary  in  different  cases. 

In  this  and  in  the  purulent  form  the  discharge  is  increased  by  a 
free  secretion  from  the  mucous  and  sebaceous  glands,  and  this  gives 
rise  to  a  very  disagreeable  odor.  There  is  also  in  most  cases  consid- 
erable pruritus. 

Causation. — In  regard  to  the  causes  of  ^ailvitis,  it  is  evident  that 
the  strumous  diathesis  and  the  lymphatic  temperament  predispose  to 
it.  All  the  cases  that  I  have  seen,  which  could  not  be  traced  to 
some  j)re-existing  or  specific  cause,  have  been  in  strumous  or  phleg- 
matic women. 

Age  also  has  its  influence.  The  j^urulent  variety  occurs  in  chil- 
dren, while  the  follicular  form  occurs  most  frequently  in  the  aged. 

Symptomatology. — These  are  not  diagnostic.  The  discharge, 
heat,  tenderness,  and  ]iruritus  are  the  chief  symptoms,  but  they 
all  occur  when  the  vulvitis  is  associated  with  vaginitis,  and  similar 
symptoms  occur  in  many  of  the  eruptive  diseases  of  the  vulva. 

Physical  Signs. — These  are  the  same  as  those  presented  by  in- 


DISEASES   OF   THE  EXTERNAL   ORGANS   OF   GENERATION.     85 

flainijaation  of  mucous  membranes  generally,  and  hence  need  not  be 
given  here. 

Diagnosis. — This  is  made  by  inspection,  and  a  careful  exclusion 
of  all  other  affections,  such  as  eruptive,  s^^ecific,  or  malignant 
disease. 

Treatment. — The  chief  objects,  in  the  management  of  vulvitis, 
are  to  keep  the  parts  clean,  and  to  separate  the  inflamed  surfaces. 
This  is  difhcult  to  do  in  children,  and  hence  the  complete  relief 
of  this  affection  in  the  young  is  not  by  any  means  easily  effected. 

In  vulvitis  of  women  I  have  of  late  years  relied  upon  frequent 
washing  with  a  solution  of  borax  or  boracic  acid,  two  or  three 
times  in  the  twenty -four  hours,  and  then  after  drying  the  parts,  ap- 
plying thoroughly  a  dry  powder  of  subnitrate  of  l:)ismuth,  oxide  of 
zinc,  or  iodoform.  This  method  answers  very  well  if  the  patient 
has  a  nurse  who  can  carefully  employ  the  treatment.  Equally  good 
results  have  been  obtained  by  applying  to  the  parts,  after  bath- 
ing thoroughly,  a  solution  of  sulphate  of  zinc,  three  or  four  grains, 
three  ounces  of  water,  and  one  ounce  of  fluid  extract  of  hydrastis 
Canadensis,  or  nitrate  of  silver,  two  grains  to  the  ounce  of  water. 
After  applying  either  of  these  lotions,  a  small  pledget  of  absorb- 
ent cotton  should  be  placed  between  the  labia,  to  keep  the  surfaces 
apart,  and  to  absorb  the  purulent  discharge. 

Inflammation  of  the  Vulvo-vaginal  Glands.  —  Inflammation  of 
these  glands  in  the  great  majority  of  cases  is  due  to  vulvitis.  The 
inflammation  extends  into  the  ducts  and  finallv  to  the  fflands  them- 
selves.  While  this  is  sometimes  the  result  in  simple  vulvitis,  it  is 
far  more  likely  to  occur  when  the  inflammation  is  gonorrhoeal.  In 
some  cases  the  inflammation  does  not  extend  beyond  the  duct,  the 
gland  itself  escaping,  and  then  there  is  but  little  discomfort  experi- 
enced by  the  patient  unless  the  purulent  discharge  keeps  up  a  cir- 
cumscribed inflammation  of  the  vulva  around  the  opening  of  the 
ducts.  When  the  glands  are  involved,  the  symptoms  are  those  of 
an  inflammation  of  the  deeper  structures.  The  closing  of  the  ducts 
of  these  glands  may  result  in  the  formation  of  cysts,  by  the  retention 
of  the  secretion. 

Symptomatology. — The  patient  will  usually  detect  the  inflamma- 
tory condition  before  the  physician  is  consulted.  This  portion  of 
the  pudendum  will  be  hot,  sensitive,  and  painful ;  pruritus  may  also 
be  present. 

Physical  Signs. — By  inspection  of  the  parts,  redness  around  the 
mouths  of  the  ducts  will  be  found.  The  openings  of  these  ducts 
are  to  be  sought  for,  about  the  middle  of  the  ostium  vaginae,  one  on 


86  DISEASES  OF   WOMEN. 

each  side,  just  in  front  of  the  hymen,  or  tlie  carunculfe  myrtifonnes. 
By  palpation  a  hard,  circumscribed  tumor  will  he  found  at  the  loca- 
tion of  the  gland. 

l^rognosls. — The  inflammation  may  gradually  subside,  or  result 
in  the  formation  of  an  abscess.  If  an  abscess  forms  it  will  pursue 
the  same  course,  and  be  recognized  in  the  same  manner  as  an  ab- 
scess elsewhere.  The  pus  may  discharge  through  the  duct,  or  it 
may  require  surgical  interference.  Rarely  the  pus  remains  encysted 
for  a  long  period.  The  intianmiation  may  confine  itself  to  the 
duct  and  not  extend  to  the  gland.  In  this  case  it  will  caase  but 
little  trouble,  pain  and  pruritus  being  present  for  a  short  time, 
and  disappearing  \nth  the  subsidence  of  the  inflammation,  or  the 
inflammation  may  result  in  adhesion  of  the  wall  of  the  duct,  and,  by 
occluding  its  lumen,  prevent  the  escape  of  the  secretion  of  the  gland, 
and  cause  a  cyst  by  its  retention.  IS^ot  infrequently  the  walls  of 
such  a  cyst  become  inflamed,  and  an  abscess  results. 

Treatment. — The  inflammation  of  these  glands  is  to  be  treated 
in  the  same  manner  as  is  recommended  for  the  treatment  of  in- 
flammation of  the  labia  majora. 

When  a  cyst  forms,  and  its  contents  can  not  be  evacuated  through 
the  duet  by  pressure,  it  may  be  dissected  out.  Although  the  great- 
est care  may  be  exercised,  this  can  not  always  be  done ;  in  that  case, 
the  cyst-wall,  after  being  exposed  by  dividing  the  mucous  mem- 
brane, may  be  opened  freely,  the  contents  of  the  sac  removed,  the 
wall  of  the  sac  thoroughly  cauterized  with  carbolic  acid,  and  the 
cavity  permitted  to  heal  from  the  bottom  by  granulation,  its  walls 
being  kept  separated  by  packing  with  cotton  in  order  to  prevent  its 
closing,  and  again  fllling. 

Inflammation  and  Abscess  of  the  Labia  Majora. — This  inflamma- 
tion occui's  in  the  connective  tissue,  which  constitutes  the  greater 
part  of  the  labia.  It  is  often  associated  with  vulvitis,  or  may  be 
due  to  the  secretions  of  the  v^agina,  wdiich  are  of  an  irritant  char- 
acter. Blows  or  other  injuries  may  also  excite  an  inflammation  in 
these  tissues.  This  inflammation  is  characterized  by  redness  and 
swelling;  the  latter  is  not  circumscribed,  as  in  the  inflammation  of 
the  vulvo-vagiual  glands,  but  is  more  diffuse.  Like  that,  however, 
it  is  painful,  and  accompanied  with  ]ji'uritus.  When  a  swelling  is 
formed  in  one  of  the  labia,  it  may  be  due  to  simple  inflammation, 
or  it  may  be  a  hernia,  an  ovary,  or  a  hematocele. 

Treatment. — The  means  employed  for  the  treatment  of  inflam- 
niation  of  connective  tissue  elsewhere  are  indicated  here.  These 
are  rest,  evaporating  lotions  containing  opium  for  the  relief  of  the 


DISEASES   OF   THE   EXTERNAL   ORGANS   OF   GENERATION.     87 

pall),  salines,  and  iiaxseed-poultices  if  the  inliamniation  dues  not 
subside.  If  an  abscess  forms,  it  should  be  opened  as  soon  as  the 
])resence  of  pus  is  determined  ;  the  opening  of  the  abscess,  and  the 
subsequent  treatment  of  the  wound,  should  be  managed  on  strictly 
untisei)tic  principles. 

Varicose  Veins  of  the  Vulva. — The  veins  about  the  vulva,  like 
those  in  other  portions  of  the  body,  may  take  on  a  varicose  condi- 
tion. This  commonly  occurs  in  those  who  have  borne  children  ;  and, 
indeed,  pregnancy  a})pears  to  stand  in  a  causative  relation  thereto, 
although  cases  undoubtedly  do  occur  in  those  who  have  never  been 
pregnant. 

Causation. — Anything  w^hich  obstructs  the  venous  circulation 
will,  by  increasing  the  intravenous  pressure,  tend  to  produce  this 
varicose  condition,  whether  it  be  a  pregnant  uterus,  a  tumor,  or,  as 
mentioned  by  Winckel,  the  straining  at  stool,  in  case  of  obstinate 
constipation. 

Sym'ptomatology . — A  patient  may  have  well-marked  varicose 
veins  of  the  vulva,  and  yet  be  entirely  unaware  of  the  fact.  Or  a 
sense  of  heat  and  irritation  may  be  experienced  of  so  disagreeable 
a  nature  as  to  cause  her  to  consult  a  physician,  when  the  presence 
of  varicose  veins  may  be  recognized.  In  still  other  cases  the  full- 
ness due  to  the  swelling  is  so  great  as  to  attract  her  attention,  though 
other  symptoms  may  be  absent. 

Physieal  Signs. — Upon  examination,  in  slight  cases,  the  varicose 
condition  of  the  veins  is  observed.  There  may,  however,  in  more 
aggravated  cases  be  so  much  tumefaction  of  the  labia  and  other  parts 
as  to  mask  this  peculiar  condition  of  the  veins.  Holden  describes  a 
ease  in  which  a  tumor  existed  as  large  as  the  head  of  a  child. 

The  diagnosis  in  these  cases  is  to  be  made  by  excluding  the  other 
affections,  by  the  methods  which  are  elsewhere  described. 

Treatment. — But  little  can  be  done  in  the  way  of  radical  treat- 
ment for  this  condition.  The  bowels  should  be  attended  to,  so  that 
tliere  may  not  be  constipation  and  the  accompanying  straining  at 
stool.  If  the  varicosity  is  marked,  and  shows  a  tendency  to  increase, 
some  relief  may  be  obtained  by  a  pad,  so  applied  as  to  give  the 
veins  the  support  which  they  lack  by  reason  of  the  weakness  of 
their  walls.  It  should  be  constantly  borne  in  mind  that,  when  these 
veins  assume  a  marked  varicose  condition,  there  is  a  possibility  of 
their  becoming  so  distended  during  pregnancy  as  to  rupture  at  the 
time  of  delivery. 

Wounds  of  the  Pudendum. — These  injuries  are  of  three  kinds — in- 
cised, punctured,  and  contused.     They  are  of  great  interest,  owing 


8b  D18EA8ES   OF    WOMEN. 

to  the  profuse  hsBinorrhage  which  usually  occurs  when  the  vessels 
of  the  Ijulbi  vestibulares  urc  W(junded.  Su])urHciul  wounds  of  the 
labia  are  not  usually  important ;  it  is  only  when  the  larj^er  vessels 
of  the  bulbi  are  opened  that  profuse  and  dangerous  haemorrhage 
occurs. 

Incised  and  punctured  wounds  are  usually  caused  by  faUing  upon 
cutting  instruments.  I  have  not  had  any  pereonal  experience  with 
such  injuries.  All  I  ku(jw  about  them  I  have  gathered  from  Sir 
James  Y.  Simpson's  obstetric  work.  lie  calls  attention  to  several 
fatal  cases  of  this  injury,  death  occurring  from  ha3niorrhage.  lie 
also  states  that  several  of  these  fatal  cases  were  su])posed  to  be  caused 
by  criminal  intent.  I  remember,  when  a  boy,  reading  an  account  of 
a  gypsy  woman,  in  Scotland,  who  died  from  pudendal  hemorrhage, 
and  her  husband  was  tried  for  her  murder.  The  defense  set  up 
was,  that  the  wound  was  caused  by  striking  against  a  stick  while 
squatting  down  to  urinate,  in  the  woods,  where  they  were  encamped. 

Thomas  records  a  case,  not  fatal,  I  believe,  which  was  caused  by 
a  piece  of  china,  from  the  breaking  of  a  _pot  de  cJiamhre. 

Sijmptomatoloij ij . — The  symptoms  are  pain  and  profuse  haemor- 
rhage, following  an  injury  to  these  })arts.  The  bleeding  is  suffi- 
ciently alarming  to  require  an  examination,  when  the  character  of 
the  injury  is  at  once  detected. 

Causation. — The  causes  are  traumatic,  and  need  not  be  discussed. 

Treatment. — The  treatment,  commended  by  most  authors,  is  to 
use  cold  a]3plications  and  astringents,  such  as  persulphate  of  iron  and 
tannin,  and  if  these  are  not  sufficient,  to  enlarge  the  wound,  pack 
it  with  antiseptic  cotton,  and  ap])]y  pressure.  To  make  the  pressure 
effectual,  the  vagina  should  be  tamponed,  and  a  compress  and  bimd- 
age  applied. 

I  am  satisfied  that  this  kind  of  treatment  must  prove  very  un- 
satisfactory. Although  I  have  had  but  little  experience  with  acci- 
dental injuries  of  the  pudendum,  I  have  repeatedly  encountered  pro- 
fuse bleeding  from  vessels  of  the  l)ulb,  wounded  while  removing 
morbid  growths  from  the  pudendum.  In  such  cases  I  have  found 
it  most  satisfactory  to  ligate  the  bleeding  points,  taking  up  the  ves- 
sels en  masse  when  several  of  them  were  wounded  ;  when  it  lias 
been  difficult  to  find  the  vessels  and  secure  them  in  the  deep  wounds, 
I  have  passed  a  strong  suture  from  the  outer  side  of  the  labia  into 
the  vagina,  and  returned  it  so  that  it  would  include  the  bleeding 
vessels  in  its  grasp  when  tightly  tied.  This  controls  the  bleeding 
for  the  time,  but  occasionally  it  will  start  again,  when  the  ligature 
becomes  loosened,  wliich  it  is  likelv  to  do  in  a  few  hours.     When 


DISEASES   OF   THE   EXTERNAL  ORGANS   OF   GENEIiATIOX.     89 

this  occurs,  the  liguturc  should  be  tightened.  If  there  is  no  subse- 
(|iient  bleeding,  the  suture  can  be  removed  at  the  end  of  twenty-four 
liours.  1  am  sure  that  this  is  the  most  surgical  as  well  as  the  most 
satisfactory  way  of  managing  Iisemorrhage  in  this  region.  Styptics 
and  pressm'e,  in  some  cases,  will  only  conceal  the  bleeding,  but  not 
arrest  it ;  the  blood  will  burrow  in  the  soft  tissues  and  complicate 
the  injury,  and  also  make  ligature  of  the  vessels  more  difficult. 

Contused  Wounds  of  the  Pudendum. — These  are  of  two  degrees  of 
severity.  A  slight  bruise,  causing  rupture  of  only  a  few  small  ves- 
sels (which  very  soon  stop  bleeding),  gives  rise  to  an  ecchymosis, 
which  quickly  disappears.  Occasionally  inflammation  follows  and 
an  abscess  develops,  which  is  managed  in  the  usual  way. 

Contused  wounds,  w^hich  rupture  the  large  vessels  of  the  bulbi 
vestibulares,  or  varicose  veins  of  the  labia,  if  any  such  exist,  produce 
pudendal  h^ematocele — i.  e.,  an  accumulation  of  blood  in  the  loose 
cellular  tissue  of  the  parts.  The  pathology  of  this  injury  is  the 
same  as  that  of  bruises  or  contused  wounds  generally.  There  are 
lacei'ation  of  the  vessels,  and  hsemorrhage  into  the  cellular  tissue. 

In  contusion  of  the  pudendum  there  are  two  conditions  which 
conspire  to  make  the  injury  grave  in  character — the  large  size  of 
the  vessels  wounded,  and  the  loose  character  of  the  cellular  tissue, 
which  admits  of  a  very  large  accumulation  of  blood.  The  size 
of  the  hnematocele  depends  upon  the  size  of  the  vessels  lacerated. 
In  case  the  vessel  is  small,  the  bleeding  may  be  controlled  by  the 
pressure  from  the  blood  in  the  tissues ;  but  when  large  varicose  ves- 
sels or  the  vessels  of  the  bulb  of  the  vestibule  are  lacerated,  the  size 
of  the  hagmatocele  is  very  great.  I  have  seen  one  nearly  as  large  as 
the  two  fists. 

The  course  and  termination  of  hsematocele  vary.  If  the  blood- 
clot  is  small,  it  may  disappear  by  absorption,  without  causing  much 
discomfort,  after  the  first  pain  of  the  injury  subsides  ;  but  when  the 
accumulation  of  blood  is  large,  then  inflammation  follows,  which  may 
terminate  in  sloughing  or  supjDuration,  and  finally  septicsemia. 

Synvptomatology . — The  symptoms  are  pain  following  the  injury, 
and  then  a  feeling  of  fullness,  heat,  and  sometimes  throbbing.  In 
one  case  that  came  under  my  observation  the  pressure  was  sufficient 
to  prevent  urination,  and  it  was  very  difficult  to  pass  the  catheter. 
The  attention  of  the  patient  being  directed  to  the  location  of  the 
injury,  the  swelling  is  discovered  by  the  touch. 

Physical  Signs. — The  physical  signs  vary  in  the  different  stages 
of  the  disease.  At  first,  the  tumor  is  elastic  and  like  a  local  (edema, 
except  that  it  does  not  pit  on  pressure.     iVfter  the  blood  has  coagu- 


90  DISEASES   OF    WOMEN. 

lated  tlie  parts  ai*e  denser  and  slightly  irregular,  or  slightly  nodu- 
lar; discoloration  of  the  skin  occurs  in  twenty-four  hours,  or  less. 
QCdenia  of  the  skin  also  appears. 

Diagnosis. — In  regard  to  the  diagnosis,  it  may  be  said  that 
pudendal  ha^iuatocele  can  hardly  he  ooiifoiuKk'd  with  any  of  the 
diseases  uf  the  jjudenduni,  except  j)udendal  hernia,  and  the  mode  (jf 
development  and  physical  signs  of  the  two  affections  are  so  uidike 
that  the  differentiation  is  easy. 

Causation. — The  causes  of  pudendal  haematocele  are  predispos- 
ing and  exciting.  Varicose  conditions  of  the  vessels,  degeneration 
of  the  vessel-walls,  and  marked  engorgement  from  any  cause  which 
interrupts  the  venous  circulation,  render  the  vessels  more  liable  to 
rupture  when  subjected  to  any  injuiy. 

Pregnancy  predis})oses  to  rupture  of  the  pudendal  vessels,  and 
labor  is  one  of  the  most  prominent  of  the  exciting  causes,  but  the 
present  discussion  of  this  affection  is  limited  to  causes  occurring  in 
the  non-puerperal  state.  The  reader  will  iind  a  very  full  account  of 
this  affection,  as  it  occurs  in  labor,  in  a  monograph  by  Prof.  Fordyce 
Barker. 

In  regard  to  the  exciting  causes  of  the  affection,  it  may  be  said, 
in  brief,  that  they  are  always  traumatic.  Direct  blows  are  the 
usual  means  by  which  the  vessels  are  ruptured ;  indirect  injuries — 
from  a  fall,  for  instance — might  produce  rupture  of  the  pudendal 
vessels,  but  I  have  not  seen  any  cases  in  which  the  injury  was 
caused  in  that  way. 

Treatment. — AYlien  the  patient  is  seen  immediately,  and  while 
haemorrhage  is  still  going  on,  an  effort  may  be  made  to  arrest  the 
bleeding  by  pressure ;  but  if  this  fails  after  a  short  trial,  it  is  best  to 
lay  tlie  parts  open,  and  secure  the  bleeding  vessels  in  the  way  already 
descri1)ed.  This  is  quite  an  important  operation,  and  recjuires  that 
the  patient  should  be  anaesthetized,  but  the  results  fully  justify  the 
means.  The  advantages  of  this  treatment  are  threefold :  the  bleed- 
ing is  controlled  effectually,  and  in  the  safest  way,  providing  the 
surgeon  is  called  while  the  bleeding  is  still  going  on  ;  the  extent  of 
inHammatory  action  is  greatly  lessened  or  wholly  avoided ;  and  the 
dangers  of  septien^mia  are  guarded  against  by  clearing  out  the  blood- 
clots  and  securing  free  drainage.  The  rule  is,  however,  that  the 
surgeon  is  not  called  until  the  stage  of  bleeding  is  jiast ;  it  is  then 
well  to  wait  till  the  patient  has  recovered  from  the  loss  of  blood,  and 
reaction  from  the  shock,  if  there  has  been  any,  has  set  in,  and  then 
lay  open  the  lupmatocele,  turn  out  the  clots,  tie  any  vessels  that  may 
bleed,  secure  free  drainage,  and  use  ordinary  surgical  dressing.     I 


DISEASES  OF  THE  EXTERNAL  ORGANS   OF  GENERATION.     91 

am  sure  that  tliis  course  of  treatment  is  the  best,  being  hy  far  the 
safest  in  guarding  against  fatal  septicaemia,  and  securing  a  more 
pi-ompt  convalescence,  with  infinitely  less  danger  to  the  tissues  of 
the  pudendum. 

ILLUSTRATIVE     CASE. 

Pudendal  Haematocele. — A  dissij^ated  woman,  about  forty  years  of 
age,  was  brought  into  the  Long  Island  College  Hospital,  after  having 
received  a  brutal  beating  from  her  husband.  She  had  a  number  of 
bruises  about  her  head  and  face,  and  complained  of  pain  in  the  puden- 
dum. On  examination,  an  enormous  swelling  was  found  in  the  region 
of  the  right  labium.  Pressure  was  made  by  means  of  liandages,  and 
the  swelling,  due,  no  doubt,  to  haemorrhage,  was  controlled  so  that 
it  did  not  increase.  She  had  considerable  fever  and  depression  from 
her  injuries,  but  was  rallied  by  means  of  stimulants  and  quinine. 
At  the  end  of  forty-eight  hours  after  her  admission  the  ecchymosis 
was  so  marked,  and  pressure  upon  the  tissues  so  great,  that  slough- 
ing was  apprehended  ;  even  if  that  should  not  take  place,  the  exten- 
sive inflammation  and  suppuration,  which  necessarily  must  follow, 
would  have  placed  the  patient's  life  in  great  danger  from  septicaemia, 
and  made  convalescence,  at  least,  very  tedious. 

It  was  tlierefore  decided  to  operate,  which  was  done  as  follows : 
An  incision  about  four  inches  long  was  made  on  the  inner  side  of 
the  tumor  with  the  thermo-cautery  knife.  Proceeding  slowly  with 
the  instniment  at  a  dull-red  heat,  no  haemorrhage  was  excited  by 
the  incision.  The  clot,  a  very  large  one,  was  turned  out,  and,  just 
as  soon  as  the  pressure  was  removed,  bleeding  started  at  several 
points  in  the  deeper  portion  of  the  wound.  The  bleeding  vessels 
were  caught  ujd  by  compression-forceps  and  ligated,  and  the  general 
oozing  which  kept  u.p  was  controlled  by  the  cauter}^  The  wound 
was  then  packed  with  lint,  which  was  held  in  place  by  a  bandage ; 
the  dressing  was  changed  night  and  morning,  the  quantity  of  lint 
being  reduced  as  the  cavity  contracted. 

She  made  an  excellent  recovery,  and  left  the  hospital  in  two 
weeks  from  the  time  of  the  operation. 

Hernia  of  the  Pudendum. — Two  varieties  of  hernia  may  occur  in 
the  vulva — one  known  as  anterior-labial,  and  the  other  as  poste- 
rior-labial. The  former,  which  is  sometimes  described  as  inguinal 
labial  hernia,  consists  in  the  passage  of  the  dislocated  oi'gan  by  the 
side  of  the  round  ligament  into  the  labia  majora.  The  sac  may  con- 
tain intestine,  omentum,  ovary,  Fallopian  tube,  or  uterus.  Winckel 
found  six  cases  of  this  variety  of  hernia  in  5,600  private  patients  ex- 
amined by  him ;  in  one  case  an  ovary  was  found  in  the  left  side ; 


92  DISEASES   OF   WOMEN. 

in  a  second,  each  ovary  in  a  hernial  sac  ;  in  a  tliii<l.  the  litems;  and 
in  a  fourth,  the  pregnant  utei-iis. 

The  second  variety,  known  also  a,s  vaginolabitd  hernia,  occurs 
niucli  less  fre(|uently.  Winckel  has  seen  but  two  cases,  and  says  that 
the  hernia  pa.^ses  down  in  front  of  the  broad  ligament  into  an  open- 
ing in  the  pelvic  fascia  and  levator  ani,  and  appears  at  the  posteiior 
extremity  of  one  of  the  lal)ia  niajora. 

Diagnosis. — This  is  not  dithcult,  if  due  caution  and  care  be  ex- 
ercised. If  the  patient  bears  down,  the  size  of  the  tumor  will  be 
increased.  If  she  be  placed  in  the  knee-chest  position,  the  hernia 
can  be  readily  reduced,  going  back  with  a  gurgling  sound.  When 
she  assumes  an  upright  position,  the  reduced  tumor  will  again 
return. 

Treatment. — This  consists  in  reducing  the  hernia,  and  retaining 
the  organ  in  place  by  means  of  a  properly -applied  truss. 

Vaginal  Enterocele. — This  is  a  form  of  hernia  in  which  the  intes- 
tines descend  into  the  pelvic  cavity,  and  may  pass  down  either  in 
front  of  or  behind  one  of  the  broad  ligaments. 

The  hernia  is  usually  composed  of  small  intestine  alone,  though 
it  may  contain  omentum  alone,  or  both  intestine  and  omentum  to- 
gether. Cases  have  been  recorded  in  which  the  large  intestine  came 
doM'ii  instead  of  the  small  one. 

Vaginal  enterocele  is  usually  explained  in  the  following  manner : 
The  intestine,  having  found  its  way  into  Douglas's  rul-de-sa^j.,  pushes 
it  downward,  and  gradually  causes  the  vagina  to  bulge  inward.  This 
may  increase  to  such  a  degree  that,  finally,  the  tumor  may  appear  at 
the  vulva  and  even  protrude  from  it. 

Diagnosis. — This  is  not  difficult  if  the  examination  is  made  with 
care,  though  serious  erroi*s  have  been  made  by  surgeons,  the  tumor 
being  considered  an  abscess,  and  opened  by  the  Icnife. 

A  vaginal  enterocele  may  be  recognized  by  the  following  char- 
acteristics: It  becomes  smaller  on  pressure;  increases  in  size  when 
the  patient  coughs  or  bears  down  ;  is  resonant  on  percussion — though, 
if  the  contents  are  omentum,  this  sign  would  not  be  present — and  is 
ea.sily  returned  if  the  patient  be  placed  in  the  knee-chest  position. 
It  may  be  mistaken  for  an  abscess,  a  prolapsus  of  the  vagina,  an 
ovarian  cyst,  or  a  dropsy  of  the  Fallopian  tubes. 

Causation. — Parturition  is  considered  as  the  most  common  cause 
of  the  hernia,  the  intestines  being  pressed  down  against  the  relaxed 
pelvic  tissues  by  the  exjnilsive  pain  of  lal)or.  "When  occurring  in 
nullipai'ous  patients,  it  is  usually  due  to  falls  or  to  violent  straining 
efforts. 


DISEASES  OF  THE   EXTERNAL  ORGANS  OF  GENERATION.     93 

Treatment. — Inasmuch  us  the  sac  of  this  variety  of  hernia  is  not 
liable  to  constriction,  strangulation  rarely  occurs.  The  tumor  will 
disappear  if  the  patient  is  placed  in  the  knee-chest  position,  and  its 
retention  may  usually  be  accomplished  by  a  pessary  that  will  keep 
the  vaginal  wall  tense.  This  will  at  least  prevent  the  protrusion  of 
the  hernia  from  the  vulva,  though  it  is  doubtful  if  any  treatment 
will  })revent  entirely  the  entrance  of  the  intestines  into  the  pelvic 
cavity.  The  existence  of  this  hernia  should  be  borne  in  mind  in 
case  the  patient  becomes  pregnant,  for  under  such  circumstances 
labor  is  often  impeded  by  the  enterocele,  which,  coming  down  in 
advance  of  the  presenting  part,  offers  a  serious  obstacle  to  its  progress. 

Hydrocele  of  the  Round  Ligament. — In  order  to  understand  the 
condition  which  is  present^in  hydrocele,  it  is  necessary  to  recall  the 
anatomical  relations  of  the  round  ligaments  and  the  labia  majora. 

The  labia,  it  will  be  remembered,  are  the  analogues  of  the  male 
scrotum,  and  the  round  ligament  of  the  spermatic  cord.  These  liga- 
ments terminate  in  the  labia  majora,  and  are  covered  by  an  offshoot 
from  the  peritonaeum,  the  increased  serous  secretion  formed  by  this 
membrane  constituting  hydrocele. 

Although  the  peritoneal  sac  does  not  ordinarily  extend  into  the 
inguinal  canal,  still  it  may  do  so,  and  intestine  or  an  ovar}^  may  en- 
ter this  pouch.  Hydrocele  of  the  round  ligament  is  liable  to  be 
confounded  with  hernia.  The  tumor  will  be  translucent  if  it  be 
hydrocele,  and  this,  together  with  the  history,  will  be  sufficient  to 
make  the  diagnosis.  An  aspirator  needle  may  be  employed  to  make 
the  diagnosis  more  certain.  It  is  an  exceedingly  rare  disease,  and 
one  that  I  have  never  seen. 

Treatment. — The  fluid  contents  of  the  sac  should  be  withdrawn 
by  aspiration,  and  tincture  of  iodine  injected. 

Hypersesthesia  of  the  Vulva. — This  disease,  as  the  name  implies, 
is  characterized  by  a  supersensitiveness  of  the  vulva.  Pruritus  is 
absent,  and  on  examination  of  the  parts  affected  no  redness  or  other 
external  manifestation  of  the  disease  is  visible.  When,  however, 
the  examining  finger  comes  in  contact  with  the  hyper^esthetic  part, 
the  patient  complains  of  pain,  which  is  sometimes  so  great  as  to 
cause  her  to  cry  out.  Indeed,  the  sensitiveness  is  occasionally  so 
exaggerated  as  to  keep  the  patient  from  consulting  her  physician 
until  it  becomes  absolutely  intolerable.  Sexual  intercourse  is  equally 
painful,  and  becomes  in  aggravated  cases  impossible. 

This  affection  must  not  be  confounded  with  vaginismus,  or  with 
other  conditions  of  increased  sensitiveness  of  the  vulva  due  to  iu- 
flammatorv  conditions. 


94  DISEASES   OF   WOMEN. 

Causation. — The  causes  which  produce  this  hyperjEsthetic  con- 
dition of  the  vulva,  when  not  (hie  to  iiiHaiuniation  or  the  pressure 
of  urethral  tumors,  are  ditHcult  to  recognize.  At  the  menopause 
the  afi'eetion  seems  more  likely  to  occur  tiian  at  any  other  period  of 
life,  and  women  of  weak  mental  and  physical  powei's  are  more  often 
its  subjects  than  those  who  are  strong  both  in  mind  and  body. 

Treatment. — Various  methods  of  treatment  have  been  suggested, 
but  so  far  as  my  own  experience  is  concerned  they  have  been  in 
most  instances  unsatisfactory.  The  sensitive  tissue  has  been  dis- 
sected off  and  relief  obtained  for  a  time,  the  hyperesthesia  return- 
ing, however,  as  before  the  operation.  Nitric  acid  has  been  ap- 
plied, but  without  a  cure  resulting.  The  best  that  we  can  probably 
do  for  our  patients  is  to  build  them  up  with  tonics  and  nutritious 
food,  and,  if  possible,  to  send  them  away  so  that  they  can  have  the 
benefit  of  a  change  of  air  and  of  scene,  and  at  the  same  time  be  re- 
moved from  the  irritation  of  sexual  intercoui'se,  which  of  necessity 
aggravates  and  perpetuates  the  hypercesthesia.  I  have  repeatedly 
been  able  to  relieve  the  hyperaasthesia,  temporarily,  by  the  applica- 
tion of  cocaine  in  a  four-percent  solution.  This  will  also  be  found 
useful  when  making  examinations  in  cases  of  sensitive  \'Tilva,  or  in 
passing  the  sound  into  a  sensitive  uterus. 

Pruritus  Vulvae. — This  condition  is  a  symptom  rather  than  a  dis- 
ease in  and  of  itself,  and  yet  it  is  such  a  prominent  one  in  many  cases 
as  to  justify  its  description  as  an  independent  affection. 

Pathology.-— ^\'\\.rii\\.^  consists  essentially  in  an  irritable  condition 
of  the  nerves  of  the  part  affected.  Although  this  is  ordinarily  the 
vulva,  it  may  be  and  often  is  the  vagina  and  the  anus,  and  even  the 
integument  of  the  abdomen  and  thighs  may  be  involved. 

Symptoms. — The  patient  notices  an  itching  of  the  parts  affected, 
which  is  at  first  relieved  by  scratching  or  rubbing,  but  later  this 
relief  is  but  temporary,  and  the  friction  aggravates  the  original  trouble, 
until  an  eruption  of  an  irritating  nature  appears,  from  which  at  a 
still  later  period  there  is  an  exudation,  which,  by  the  nails  used  in 
scratching,  or  in  other  ways,  is  carried  to  other  portions  of  the  body, 
and  seems  by  its  irritant  nature  to  excite  a  similar  trouble  there. 
The  itching  and  the  burning  sensations  become  at  times  intolerable, 
and  the  patient  is  debarred  from  the  society  of  her  friends.  In  some 
instances  the  annoyance  and  suffering  are  increased  at  night,  and  in 
order  to  obtain  sleep  hypnotics  have  to  be  administered. 

PJrydcal  Signs. — It  is  more  than  jirobable  that  pruritus  is  always 
secondary  to  some  other  trouble.  A  due  appreciation  of  this  fact  is 
necessary  for  the  institution  of  proper  treatment,  as,  if  it  is  lost  sight 


DISEASES   OF  THE   EXTERNAL  ORGANS   OF  GENERATION.     95 

of,  and  that  wliich  is  in  reality  only  a  symptom  is  regarded  as  a  disease, 
the  pruritus  will  continue  almost  indefinitely,  and  in  its  chronic  form 
will  resist  all  remedial  measui'es.  LeucorrhcEa  is  very  commonly  as- 
sociated with  pruritus,  and  appears  to  stand  in  a  causative  relation 
thereto.  Other  irritating  fluids  may  also  produce  the  same  result. 
Of  these  the  most  common  are  diabetic  urine  and  the  discharges 
from  an  ulcerating  cancer  of  the  uterus.  The  leucorrhoeal  discliarge 
which  is  most  likely  to  produce  pruritus  is  that  from  a  uterus  which 
is  the  seat  of  endometritis,  either  cervical  or  corporeal. 

The  presence  of  parasites  may  also  account  for  the  existence  of 
pruritus. 

Treatment. — From  the  principle  already  laid  down  that  pruritus 
is  to  be  regarded  as  a  symptom  of  some  pre-existing  disease,  the  de- 
tection of  this  disease  will  iirst  demand  attention,  and  when  discov- 
ered treatment  appropriate  thereto  should  follow.  If  there  be  an 
endometritis,  the  discharge  from  which  irritates  the  vulva  or  other 
parts,  and  causes  pruritus,  the  inflammation  should  be  treated  as 
advised  elsewhere. 

A  pledget  of  absorbent  cotton  placed  against  the  os,  to  receive 
the  discharge,  will  be  of  great  benefit ;  this  should,  of  course,  be 
renewed  sufficiently  often.  Yaginal  douches  containing  acetate  of 
lead  or  carbolic  acid  will  often  give  great  relief.  Snbnitrate  of  bis- 
muth may  be  dusted  on  to  prevent  friction  of  the  labia  against  each 
other ;  this  sometimes  relieves  the  pruritus.  I  have  found  this  to 
be  one  of  the  best  local  applications  in  the  pruritus  caused  by  diabe- 
tes; in  such  cases  I  direct  the  patient  to  keep  the  urine  from  coming 
in  contact  with  the  parts,  as  far  as  possible,  when  urinating,  and  to 
dry  the  pudendum  and  dust  it  over  with  snbnitrate  of  bismuth.  By 
adding  an  equal  quantity  of  prepared  chalk  to  the  bismuth,  it  makes 
a  powder  that  is  more  easily  used. 

Very  satisfactory  results  can  be  obtained  in  the  management  of 
cases  where  the  pruritus  is  caused  by  some  appreciable  disease  of  the 
organs.  The  greatest  difliculties  are  experienced,  however,  in  the 
treatment  of  that  form  of  pnzritus  which  occurs  without  any  lesion 
of  structure  or  accompanying  affections  to  account  for  it.  That 
there  are  some  morbid  changes  in  the  tissues,  in  the  violent  pruritus 
which  is  experienced,  is  no  doubt  tnie,  but  so  far  they  have  not  been 
demonstrated  by  pathologists,  and  hence  the  majority  of  authors  con- 
sider that  this  affection  is  a  neurosis. 

In  the  majority  of  cases  of  this  kind  that  have  come  under  my 
obseiwation,  the  skin  has  been  bleached,  in  spots  ap])earing  whiter 
than  the  normal  skin.    It  has  also  lost  the  normal  elasticity.    To  the 


90  DISEASES    OF    WOMEN. 

touch  it  seems  h<arder  and  less  flexible,  but  what  these  changes  are, 
and  whether  they  are  related  to  the  pruritus,  are  questions  which 
have  not  yet  been  answered. 

The  pathology  and  causation  of  this  atfection  are  both  obscure, 
and  the  treatment  is  equally  unsatisfactory.  ^Many  of  these  cases 
prove  to  be  incurable,  and  in  some  it  is  not  possible  to  give  the  patient 
complete  reHef  by  any  local  treatment.  This  has  led  to  the  use  of  a 
great  variety  of  agents,  but  none  of  them  has  proved  to  be  reliable 
in  all  cases.  The  remedies  that  have  given  the  best  results  in  my 
practice  are  bichloride  of  mercury  and  emulsion  of  bitter  almonds, 
one  grain  to  the  ounce  ;  this  is  applied  to  the  parts  atfected  twice  a 
day.  A  powder  composed  of  one  grain  of  morphine  to  two  grains 
of  chalk,  to  be  applied  night  and  morning ;  equal  parts  of  tincture 
of  opium,  iodine,  and  aconite,  and  eight  per  cent  of  carbolic  acid, 
applied  once  a  day — all  of  these  have  been  tried,  and  each  one  has 
proved  serviceable  to  some  extent,  Ijut  there  are  cases  which  resist 
all  these  remedies. 

The  bichloride  of  mercury  mixture,  used  alone,  has  been  of  the 
most  service  in  the  largest  number  of  cases.  Where  it  fails,  I  have 
used  a  solution  of  iodoform  in  ether;  this  is  applied  by  means  of  an 
atomizer,  and  by  using  strong  air-pressure  the  solution  is  forced  into 
all  the  folds  of  the  mucous  membrane ;  the  ether  soon  evaporates,  and 
leaves  a  fine  coating  of  the  iodoform  over  the  whole  surface.  This 
nearly  always  relieves,  and  if  applied  frequently  is  curative  in  some 
cases.  I  have  also  used  carbolic  acid  and  tincture  of  iodine,  equal 
parts,  and  this  nearly  always  gives  relief  for  a  day  or  more.  In  the 
following  case  this  application  relieved  the  pruritus  permanently : 

The  patient  had  passed  the  menopause,  and,  although  she  had 
not  borne  children,  her  health  had  always  been  good.  Dr.  Fordyce 
Barker,  whom  she  consulted,  sent  her  to  me,  telling  her  at  the  same 
time  that  I  could  not  cure  her,  but  would  give  her  as  much  relief  as 
possible.  I  tried  the  usual  remedies,  with  no  bcnetit.  I  then  used 
the  carbolic  acid  and  iodine,  but  found  it  difficult  to  apply  to  all  the 
irregularities  of  the  surface.  I  applied  it  with  the  atomizer,  using 
a  high  pressure,  so  that  the  solution  was  forced  into  the  tissues,  and 
a  deeper  effect  obtained  than  1  had  expected.  The  result  of  this 
was,  that  the  patient  suffered  greatly.  The  first  effect  was  sharp 
pain,  followed  very  soon  by  relief  from  the  itching,  and  numbness 
of  the  parts;  in  short,  the  anaesthetic  effect  of  the  carbolic  acid  was 
obtained  in  a  marked  degree.  Following  this  there  were  great  irri- 
tation and  pain  ;  tlie  epithleial  layers  of  the  skin  and  mucous  mem- 
brane came  off"  as  if  they  had  been  blistered,  and  there  was  much 


DISEASES   OF   TUE   EXTERNAL   ORGANS   OF   GENERATION.     97 

sensitiveness.  During  this,  while  the  patient  was  suffering  tlie 
most  j^ain,  she  said  that  it  caused  far  less  suffering  than  the  itching. 
When  she  recovered  from  the  treatment  the  itching  did  not  return 
for  several  weeks,  and  then  only  in  a  slight  degree.  I  made  the 
same  application  once  again  to  several  spots  where  there  was  severe 
itching,  being  careful  not  to  cover  more  than  a  very  small  area.  It 
was  not  necessary  to  apply  tlie  remedy  the  third  time. 

She  completely  recovered,  and  remained  well  for  one  year  at 
least ;  and  I  presume  she  has  had  no  relapse,  as  I  should  probably 
have  heard  from  her  if  she  had. 

Eruptions  of  the  Vulva. — The  vulva  may  be  the  seat  of  eczema, 
either  acute  or  chronic,  herpes,  prurigo,  erysipelas,  and  diphtheria. 

Eczema  here  as  elsewhere  consists  of  vesicles,  or  a  somewhat 
reddened  skin,  from  which  a  serous  fluid  escapes.  This  dries,  and 
oftentimes  a  thick  crust  forms,  under  which  pus  may  accumulate. 
If  the  attack  does  not  become  chronic,  this  crust  falls  off  in  one  or 
two  weeks,  exposing  a  new  and  tender  epidermis  beneath.  If,  on 
the  other  hand,  the  affection  becomes  chronic,  the  tissues  become 
thickened  by  exudation,  and  at  the  same  time  dry,  and  lose  their 
suppleness.  This  condition  is  very  liable  to  extend  to  the  thighs 
and  to  the  integument  about  the  mons  veneris  aud  anus. 

In  herpes,  vesicles  are  also  present,  but  they  are  not  accompanied 
by  any  redness  or  inflammation  of  the  surrounding  tissues.  These 
vesicles  may  rupture  and  scales  result,  but,  like  herpetic  eruptions 
on  the  lips,  they  are  of  short  duration,  and  soon  disappear. 

In  prurigo,  small  papules  are  seen  on  the  affected  parts.  Kiihn 
desciibes  them  as  having  a  small,  dark  spot  in  the  center,  which  is 
depressed,  and  containing  a  tenacious,  reddish,  glaud-Hke  mass  at- 
tached to  the  bottom  of  the  papilla. 

Treatment. — In  the  acute  form  of  eczema,  in  which  there  is  free 
transudation  of  senim,  I  use  subnitrate  of  bismuth  or  powdered  soap- 
stone,  with  three  to  five  per  cent  of  carbolic  acid.  When  the  j^arts 
are  dry,  I  en:iploy  oxide-of-zinc  ointment,  carbolic-acid  ointment,  or 
glycerine  and  borax.  In  chronic  forms  of  eczema,  applications  of 
nitrate  of  silver,  twenty  grains  to  the  ounce  of  water,  may  be  made. 
This  may  be  done  once  or  twice  a  week.  The  herpetic  eruption 
will  disappear  without  treatment,  and  the  only  indication  is  to  keep 
the  affected  parts  protected  from  friction. 

Prurigo  may  be  cured,  according  to  Kiihn,  by  removing  these 
tenacious  masses  which  have  been  described  as  situated  at  the  bottom 
of  the  papillae. 

The  vulva  is  sometimes  the  seat  of  erysipelatous  and  diphtheritic 


98  DISEASES   OF    WOMEN. 

inflammation.  Erysipelas  is  rare  in  adult  life,  and  indeed  may  be 
said  to  oceur  most  frequently  in  the  very  earliest  infancy.  In  its 
local  treatment  sn«i;ar-()f-lead  lotions  may  be  aj)plied,  and  internally 
tonics  and  stimulants.  The  .j)rescrij)tion  which  has  given  me  the 
most  satisfaction  is  as  follows :  Borax,  one  drachm ;  tincture  of 
opium,  one  ounce ;  glycerin,  three  drachms ;  and  watei-,  three 
ounces.     The  parts  should  be  kept  constantly  moistened  with  this. 

Diphtheria  of  tlie  vulva  occurs  in  some  cases  when  the  exudation 
exists  in  the  pharynx  or  larynx,  and  rarely  as  an  independent  disease. 
Its  treatment  is  constitutional. 

Noma,  or  gangrene  of  the  vulva,  is  perhaps  best  considered  in 
connection  with  the  eruptive  diseases.  The  first  indication  is  a 
swelling  of  one  of  the  labia  majora,  wliich  becomes  of  a  grayish- 
green  color,  followed  by  vesicles ;  the  color  changes  to  brown,  and 
gangrene  rapidly  sets  in. 

Caumtion. — Xoma  occurs  in  chikb'en  whose  general  health  is 
poor,  either  from  insufficient  and  improper  food,  or  from  having  lived 
in  squalid  tenement-houses;  or,  indeed,  from  l)oth  combined.  It 
may  also  occur  as  a  compHcation  of  one  of  the  contagious  diseases — 
scarlet  fever,  measles,  or  small-pox. 

The  prognosis  in  noma  is  very  grave. 

Treatment. — This  sliould  be  directed  to  sustaining  the  failing 
powers  of  the  patient.  For  this  pui'pose  quinine,  iron,  and  stimu- 
lants should  be  freely  administered,  and  antiseptic  dressings  apjslied 
to  the  affected  parts,  it  has  been  recommended  to  excise  the  gan- 
grenous tissue,  and  to  apply  the  actual  cautery  to  the  underlying 
parts. 


CHAPTEE   YI. 

t 

DISEASES    OF    THE    VAGESTA. 

Anatomy  of  the  Vagina. — The  vagina  is  the  coiitinuation  of  the 
genital  tract  from  the  uterus  to  the  vulva.  It  is  curved  to  coincide 
with  the  axis  of  the  pelvic  excavation ;  this,  to  some  extent,  renders 
it  much  shorter  in  front  than  behind.  The  anterior  wall  is  about 
two  inches  long,  while  the  posterior  is  nearly  twice  that  length.  The 
anterior  wall  is  further  shortened 
by  the  cervix  uteri  which  joins 
the  vagina  much  nearer  to  the  vul- 
va in  front. 

Fig.  59  shows  the  comparative 
length  of  the  vagina  in  front  and 
behind. 

The  vagina  is  attached  above 
to  the  cervix,  about  midway  be- 
tween the  body  of  the  uterus  and 
the  termination  of  the  cervix  uteri. 
Below,  it  unites  with  the  floor  of 
the  pelvis  and  the  structures  which 
form  the  vulva.  Anteriorly,  it  is 
united  to  the  bladder  and  urethra ; 

to  the  former  loosely,  and  to  the  latter  so  firmly 
that  it  is  almost  impossible  to  separate  these 
structures  even  by  dissection.  Posteriorly,  the 
vagina  and  rectum  are  united  and  form  the  recto- 
vaginal septum.  Below,  they  are  separated  by 
the  sphincter-ani  and  tranversus-perinei  muscles 
and  cellular  tissue.  Fig.  60  shows  the  triangle 
formed  by  the  bifurcation  of  the  two  canals  and 
p  „    „„      '!!  .       ,      the  divided  muscles  between  them. 

JcHG.    60.  —  Trianpjular 

shape  of  perineal  body.         The  vesico- vaginal  septum  is  the  most  resist- 


FiG.  59. — Length  of  vagina,  less  in  front 
than  behind. 


100  DISEASES  OF  WOMEN. 

ant  ])orti<»ii  of  the  vaginal  walls,  and,  wlicii  put  iijxtn  the  stretch, 
feels  like  a  cord  lying  beneath  the  mucous  layer;  this  is  called  the 
anterior  cohiinn  of  the  vagina. 

The  vaginal  walls  are  composed  of  three  coats — an  external,  mid- 
dle, and  internal ;  the  extenial  consists  of  ftbrous,  elastic,  and  areo- 
lar tissue :  the  middle  of  unstri])cd  muscular  fiber ;  and  the  inter- 
nal of  mucous  membrane.  The  muscular  coat  is  continuous  with  the 
middle  coat  of  the  uterus,  and  the  two  are  alike  in  structure,  and  in 
the  fact  that  they  both  undergo  extraordinary  hypei'tro})hy  during 
iitero-eestation.  The  uuicous  membrane  of  the  vagina  is  continuous 
with  the  endometrium,  but  differs  from  the  latter  in  structure  to  a 
marked  extent.  It  is  arranged  in  transvei-se  folds,  which  are  most 
prominent  anteriorly,  and  is  studded  with  papillae  and  covered  with 
pavement  epithelium.  In  general  structure  the  mucous  membrane 
of  the  vagina  resembles  very  much  the  skin.  This  is  noticeable  in 
cases  of  prolapsus,  in  which  the  membrane,  by  being  exposed,  be- 
comes dry  and  its  epithelium  hardened. 

The  stnicture  of  this  membrane  is  like  the  skin  to  some  extent — 
its  secretion  is  serous  and  of  acid  reaction.  There  has  been  some 
discussion  among  anatomists  regarding  the  presence  or  absence  of 
muciparous  glands  in  this  vaginal  membrane.  The  fact  is  that  they 
are  abundant  in  the  lower  third,  but  nearly  absent  in  the  middle  and 
upper  thirds. 

The  vagina  is  developed  like  the  uterus,  from  Miiller's  ducts,  and 
is  lial)le  to  malformations  fi'om  arrest  or  defects  of  development. 

Malformations  of  the  Vagina. — Imperforate  hymen  has  been  al- 
ready discussed  under  the  head  of  menstrual  disorders  due  to  mal- 
formations of  the  sexual  organs  generally. 

Double  vagina  usually  occurs  in  connection  with  doul)le  utenis, 
and  in  such  cases  no  harm  to  the  patient  is  likely  to  result. 

Perpetuation  of  the  septum  between  the  most  dependent  por- 
tions of  Miiller's  ducts  has  been  found.  Li  one  jwticnt  who  came 
under  my  observation  a  thick  septum  extended  frcm  just  within  the 
hymen  upward  about  an  inch  and  three  quarters.  This  malforma- 
tion gave  rise  to  no  symptoms,  and  was  not  recognized  until  the 
birth  of  her  first  child,  when  the  attending  ])hysician  found  that  it 
caused  some  obstruction  to  delivery.  I  examined  the  case  about  two 
months  after  her  confinement  and  found  this  septum,  about  a  quarter 
of  an  inch  thick  and  quite  resistant.  It  was  divided  by  two  incis- 
ions parallel  to  the  axis  of  the  vagina,  and  aliout  three  quartei*s  of 
an  inch  apart.  The  strip  thus  removed  was  not  the  whole  of  the 
septum,  but  it  was  sufficient,  as  the  ends  remained  contracted.     The 


DISEASES   OF   THE    VAGINA.  101 

divided  edges  were  brought  togetlier  with  sutures,  and  liealing  took 
|)lace  very  promptly. 

Imperforate  Vagina. — Absence  of  the  vagina  has  been  described 
as  one  of  the  malformations,  l)ut  it  is  doubtful  if  there  is  not  in 
these  cases  a  rudiment  of  vagina,  which  is  imperforate,  and  hence 
absent  to  all  intents  and  purposes.  In  the  most  complete  case  of  the 
kind  that  I  have  seen  the  rectum  and  bladder  were  near  together. 
With  the  finger  in  the  rectum,  and  a  large  sound  in  the  bladder,  a 
rather  dense  cord  running  upward  from  the  vulva  could  be  felt. 
The  uterus  was  also  rudimentary,  and  although  the  patient  had 
passed  the  period  of  puberty,  and  had  the  outward  characteristics 
of  her  sex,  she  had  never  menstruated.  This  was  evident  from  the 
absence  of  menstrual  flow  in  the  uterus  and  Fallopian  tubes. 

In  cases  like  this  nothing  can  be  gained  by  treatment.  So  long 
as  there  is  no  excessive  menstruation,  which  would  endanger  the  life 
of  the  patient,  there  should  be  no  interference. 

Atresia  of  the  Vagina. — This  is  the  more  common  affection.  It 
may  be  either  complete  or  partial,  congenital  or  acquired. 

In  the  congenital  form  the  atresia  may  extend  the  whole  length 
of  the  vagina,  and  that  condition  is  generally  associated  with  an  un- 
developed uterus.  The  incomplete,  or  partial,  atresia  is  usually  at 
the  lower  third,  but  it  may  occur  at  the  upper  or  middle  portion  of 
the  vagina. 

Congenital  atresia  occurs  under  two  different  conditions.  The 
one  is  associated  with  defective  development  of  the  uterus  or 
ovaries,  or  both,  sufficient  to  prevent  menstruation  altogether.  In 
the  other,  menstruation  takes  place,  but  the  flow  being  obstructed, 
accumulation  occurs  in  the  uterus  and  sometimes  in  the  Fallopian 
tubes.  These  differing  conditions  require  different  management.  I 
will  therefore  consider  them  separately. 

Atresia  of  the  vagina,  with  defective  development  of  the  uterus 
and  ovaries,  is  only  of  interest  with  reference  to  the  diagnosis.  Noth- 
ing can  be  done,  nor  is  there  any  active  demand  for  treatment.  The 
patient  does  not  suffer,  as  a  rule,  except  from  the  consciousness  of 
her  deformity,  which  would  only  cause  mental  distress  in  case  she 
intended  to  get  married. 

Two  such  cases  have  come  under  my  observation.  The  most 
typical  one  was  of  a  good  family,  strong,  but  inclined  to  flesh.  She 
did  not  change  much  in  general  appearance  at  puberty,  but  main- 
tained considerable  of  the  masculine  type.  She  never  showed  the 
slightest  disposition  to  menstruate.  She  was  asked  by  a  worthy 
man  to  marry,  but  she  was  afraid  to  do  so  without  advice,  kno"\vang 


102  DISEASES   OP^   WOMEN. 

that  she  was  "  unliku  other  women."  She  sought  advice,  and  on  ex- 
amination there  was  found  atresia  of  the  vagina,  and  a|)parently  the 
uterus  and  ovaries  were  rudimentary.  Nothing  could  be  done  to 
lielp  her.  She  took  up  nui*sing  as  a  profession,  and  lias  succeeded 
remarkably  well.  This  case  is  briefly  given  in  order  that  this  variety 
may  be  contrasted  with  the  next  form. 

Atresia  associated  with  fully  developed  utenis  and  ovaries  may 
be  complete  or  incomplete.  Usually,  there  is  no  notice  taken  of  the 
deformity  until  puberty  arrives,  unless  the  attention  of  the  mother 
or  physician  is  directed  to  the  pelvic  organs  for  some  other  reason. 
There  are  no  s^nnptoms  until  puberty.  Then  the  patient,  after  hav- 
ing undergone  the  changes  characteristic  of  the  period,  has  all  the 
symptoms  of  menstruation  without  the  flow. 

The  symptoms,  or  menstrual  molimen,  as  they  are  called  in  their 
totality,  are  more  marked  than  in  normal  menstruation,  and  great 
pain,  fullness,  and  tenesmus,  come  on  during  the  period.  The  tirst 
effort  at  menstruation  is  not  usually  attended  with  such  severe  suf- 
fering, but  each  succeeding  period  is  worse,  and  very  soon  the  evi- 
dences of  the  accumulated  fluid  become  tangible. 

Physical  Signs. — Inspection  of  the  parts  shows  a  complete  closure 
of  the  vulva.  Combined  touch  with  a  straight  sound  in  the  bladder 
and  a  finger  in  the  rectum,  reveals  the  fact  that  in  absence  of  the 
vagina  the  rectal  and  vesical  walls  come  together,  and  are  thin  and 
elastic.  If  the  vagina  is  present,  but  closed,  it  is  felt  between  the 
sound  and  finger  as  a  firm  cord.  When  the  uterus  is  distended  with 
menstnial  fluid,  the  accumulation  causes  a  tumor,  which  is  elastic  and 
obscurely  fluctuating.  The  signs  of  partial  atresia  differ  according 
to  the  location  of  the  occlusion.  When  the  atresia  is  in  the  upper 
third  of  the  vagina  the  lower  portion  of  the  canal  ends  in  a  cul-de-sac. 
If  the  atresia  is  at  the  lower  third,  the  obstruction  is  found  below,  and, 
by  means  of  the  sound  in  the  bladder  and  the  finger  in  the  rectum, 
the  upper  portion  of  the  vagina  is  found  distended  with  menstrual  fluid. 

Causation. — Congenital  atresia  is  produced  by  some  arrest  of 
development  or  disease  during  embryonic  life.  When  it  is  acquired 
between  birth  and  puberty,  it  is  usually  due  to  acute  inflammation 
occurring  in  connection  with  some  constitutional  disease,  such  as 
scarlatina,  diphtheria,  or  measles. 

Gangrenous  vulvitis  and  vaginitis,  which  may  occur  in  the  course 
of  any  of  the  above-named  diseases,  may  also  tenninate  in  atresia. 
I  have  seen  two  cases  of  partial  atresia,  caused  h\  some  acute  inflam- 
mation during  the  com*se  of  typhoid  fever,  occurring  near  the  period 
of  puberty. 


DISEASES   OF  THE   VAGINA.  103 

In  the  cases  which  have  been  acquired  after  pul^erty  and  cliild- 
bearing,  one  was  a  soldier's  wife,  who  was  confined  of  her  first  child 
at  a  military  post  on  the  frontier.  Her  labor  was  of  three  days' 
duration,  and  she  was  finally  delivered  by  craniotomy ;  there  Avas 
subsequent  sloughing  of  the  vaginal  walls,  and  consequent  atresia. 

Another  ease  of  partial  atresia  was  caused  by  amputation  of  the 
cervix  for  cancer.  There  was  at  the  time  of  the  operation  deep  cau- 
terization of  the  vaginal  walls,  which  resulted  in  atresia.  One  other 
case  was  caused  by  the  accidental  use  of  pure  carbolic  acid,  as  a  vag- 
inal injection.  In  this  case  the  adhesions  of  the  vaginal  walls  were 
not  very  firm,  and  the  canal  was  restored  by  operation,  but  there 
was  much  trouble  experienced  in  preventing  the  recurrence  of  the 
atresia — a  constant  tendency  to  which  remained. 

Prognosis. — In  complete  atresia  there  is  great  difficulty  in  the 
operation  for  its  relief,  and  a  constant  tendency  to  contraction  of 
the  parts ;  hence,  the  hope  of  complete  recovery  is,  to  say  the  least, 
very  limited. 

Treatment. — The  indications  are  to  restore  the  vagina  by  surgical 
means.  This  is  a  difficult  procedure,  and  one  that  is  not  very  suc- 
cessful in  all  cases.  The  difficulties  in  the  operation,  and  the  ulti- 
mate success,  depend  upon  whether  the  atresia  is  partial  or  complete. 
If  the  portion  of  the  vagina  which  is  closed  is  limited  to  a  third  of 
the  whole  canal,  reasonable  hope  of  success  may  be  entertained,  but 
I  doubt  if  the  vagina  was  ever  fully  restored  and  maintained  when 
complete  atresia  existed. 

When  there  is  associated  with  the  atresia  imperfect  development 
of  the  uterus  and  ovaries,  and  there  is  no  tendency  to  menstruation, 
treatment  is  not  indicated.  Such  malformed  subjects  often  live  quite 
comfortable  and  useful  lives. 

There  is  another  class  of  cases,  already  referred  to  in  treating  of 
absence  of  the  menstrual  function,  in  which  the  uterus  and  vagina 
are  rudimentary,  but  the  ovaries  are  well  developed.  In  these  there 
is  a  recurring  menstrual  molimen,  and  the  general  nervous  system 
may  become  greatly  deranged.  Ovaro-epilepsy  may  occur  under 
these  conditions.  The  removal  of  the  ovaries  might  become  neces- 
sary in  such  cases  in  order  to  arrest  the  inclination  to  menstruation, 
and  relieve  the  constitutional  disturbance  caused  by  such  unsuccessful 
efforts. 

The  following  is  a  description  of  Dupuytren's  operation  for 
atresia  of  the  vagina,  as  described  by  Courty,  with  the  modifications 
which  M.  Puesch  has  added,  which  I  quote  from  the  work  of  Dr. 
Thomas : 


10^  DISEASES  OF  WOMEN. 

"  After  having  arranged  the  woman  in  a  convenient  position,  the 
bladder  is  emptied  by  means  of  a  male  catheter,  which  \a  given  to 
an  assistant,  who  holds  it  turned  npward.  It  is  not  removed  during 
the  operation,  except  where  the  obliquity  of  tlie  part  W(»uld  render 
it  troublesome.  The  index-tinger  of  the  left  hand  is  then  carried 
into  tho  intestine  as  far  as  possible,  in  order  to  serve  as  a  guide  for 
the  bistoury  and  at  the  same  time  as  a  protection  to  the  rectum. 
After  these  preliminary  steps  the  operator,  placed  between  the  thighs 
of  the  patient,  makes  a  transverse  incision  at  the  center  of  the  obsta- 
cle, or  in  the  vulvar  orifice,  if  the  vagina  is  completely  wanting ;  if 
the  cellular  tissue  is  lax,  he  can  tear  with  his  finger,  the  sound,  or 
the  handle  of  the  bistoury  the  vesical  and  rectal  walls  till  he  reaches 
the  tumor;  if  it  is  tense  or  too  resistant,  the  surgeon  dissects  by 
gentle  efforts,  separating  the  tissues  with  the  handle  or  the  finger 
rather  than  cutting  them,  and,  if  it  be  necessary,  breaking  them  down 
at  the  edges  with  a  button  bistoury.  In  each  case  he  proceeds  slowly 
and  carefully,  stopping  from  time  to  time  to  examine  with  the  finger 
and  be  certain  at  what  distance  those  organs  are  situated  which  it  is 
necessary  to  avoid.  When  the  canal  which  has  been  reopened  will 
admit  the  index-finger  easily,  and  when  a  more  distinct  perception 
of  fiuctuation  announces  the  proximity  of  the  sanguineous  collection, 
the  operator  is  warranted  in  plunging  a  trocar  into  this,  and  the 
pouring  out  of  a  sirupy,  brown  liquid,  like  the  lees  of  wine,  will 
show  that  the  end  has  been  reached.  The  pressure  upon  the  uterus 
is  then  stopped,  a  large  part  of  the  fluid  is  allowed  to  flow  away 
through  the  canula,  and  then,  substituting  for  this  instrument  a  per- 
forated sound,  the  operator  increases  the  size  of  the  opening  by  nu- 
merous incisions  upon  its  sides,  and  thus  renders  certain  jthe  final 
result.  Afterward  he  carries  a  gum-elastic  sound  into  the  uterine 
cavity,  and  throws  through  this,  but  with  very  little  force,  several 
injections  of  warm  water.  The  dressing  having  been  finished,  the 
parts  are  sponged  and  dried,  and  tlie  patient  is  placed  in  T)ed,  pro- 
tected with  cloths,  so  as  to  prevent  the  bedding  from  being  soiled 
by  the  mucous  and  sanguinolent  discharges  which  flow  during  the 
first  days." 

To  keep  the  canal  open  after  this  operation  is  exceedingly  ditfi- 
cult ;  all  surgeons  testify  to  this  fact.  Many  things  have  been  tried 
to  accomplish  this  object,  but  the  best  is  the  glass  plug  or  dilator  of 
Sims  (Fig.  01).  In  one  case — the  case  of  accpiired  atresia  referred 
to  under  the  head  of  causation — I  found  that  the  glass  instrument 
caused  much  pain,  and  I  used  elm-bark  cut  in  tine  stri]->s,  made  into 
a  roll  of  suitable  size,  and  moistened  with  carbolized  w;'.ter.     This 


DISEASES   OF   THE   VAGINA. 


105 


Fig.  61. — Sims's  vaginal  dilator. 


was  removed  daily,  and,  as  it  expanded  after  being  introduced,  it 
answered  in  that  case  very  well. 

Tiie  tendency  in  all  these  eases  is  to  contraction  and  return  of 
the  atresia ;  in  fact,  I 
have  never  seen  a 
case  of  complete  atre- 
sia j)ermanently  cur- 
ed. In  view  of  all 
these,  I  have  been 
guided  in  practice 
by  the  valuable  sug- 
gestions of  West. 
The  following  is  from  his  work  on  "Diseases  of  Women,"  page  34 : 

"  The  operation  .for  atresia  is  performed  by  the  bistoury  or 
guarded  bistoury,  or  Pouteau's  trocar.  The  bistoury  is  to  be  gener- 
ally preferred.  Pouteau's  trocar  is  resorted  to  when  a  considerable 
part  of  the  lower  vagina  is  absent,  and  the  sac  is  punctured  some- 
times pretty  high  up  per  rectum.  This  operation  is  in  such  cases 
preferable  to  vain,  painful,  a.nd  dangerous  attempts  to  bore  the  thin 
tissues  between  the  urethra  and  rectum  to  make  and  maintain  a  new 
vagina.  Such  a  proceeding  results  only  in  vexation.  It  is  far  better 
for  the  malformed  woman  to  discourage  all  hopes  of  n:iatemity.  The 
artificial  passage  into  the  rectum  is  easily  kept  open,  and  the  men- 
strual fluid  runs  off  through  it." 


INFLAMMATORY  AFFECTIONS    OF    THE    VAGINA. 

Vaginitis. — The  vagina  is  seldom  if  ever  affected  witli  idiopathic 
inflammation ;  vaginitis,  therefore,  always  occurs  as  the  result  of 
some  specific  cause,  or  is  secondary  to  some  contiguous  infiammation, 
such  as  endometritis.  There  are  several  varieties  of  vaginitis.  Clas- 
sified according  to  the  intensity  and  duration  of  the  affection,  there 
are  the  acute  and  chronic  forms ;  when  classified  according  to  the 
causation,  there  is  a  number  of  forms,  the  most  important  of  which 
are  gonorrhreal,  erythematous,  sometimes  called  erysipelatous,  and 
diphtheritic.  As  a  rule,  the  inflammation  is  general,  involving  the 
whole  canal ;  occasionally  it  is  circumscribed,  and  then  it  is  found 
just  within  the  vulva,  or  else  at  the  upper  part. 

Pathology. — Owing  to  the  anatomical  peculiarities  of  the  vagina 
it  is  not  susceptible  of  the  catarrhal  form  of  inflammation,  so  com- 
mon to  mucous  membranes  elsewhere.  From  the  fact  that  the  vag- 
inal mucous  membrane  resembles  in   structure  the  skin,  and  that 


100  DIbEASEb   OF    WOMEN. 

there  are  few  raucous  follicles  found  in  it,  vaginitis,  in  its  pathology, 
is  more  like  dermatitis  than  like  tlie  ordinary  intlainmations  of  mu- 
cous membranes.  Congestion,  transudation  of  serum,  premature  ex- 
foliation of  the  epithelium,  and,  in  well-defined  cases,  the  formation 
of  pus,  are  the  characteristic  results  of  acute  vaginitis. 

In  the  subacute  form  there  is  less  congestion  and  less  pus,  other- 
wise the  inflammatory  lesions  are  the  same.  This  may  all  be  more 
briefly  stated  in  aufjther  form,  as  follows :  Vaginitis  occurs  either  as 
erythematous,  purulent,  or  exudative — never  as  purely  catarrhal. 

The  morbid  appearances  in  these  forms  differ.  Erythematous 
vaginitis  is  characterized  by  great  capillary  congestion,  which  gives 
the  intense  redness  of  this  form  of  inflammation  in  tiie  first  stage. 
Then,  as  the  disease  advances,  there  is  exfoliation  of  the  epithelium. 
Sometimes  the  epithelium  comes  off  in  thin  flakes,  resembling  in 
this  respect  the  exfoliation  of  the  cuticle  in  dermatitis.  This  leaves 
the  mucous  membrane  denuded  of  its  epithelium,  and  gives  a  glazed 
appearance  to  the  whole  canal.  During  this  time  there  may  be  a 
free  serous  secretion  and  some  pus  found,  but  these  are  not  profuse 
in  all  cases. 

In  purulent  vaginitis  the  lesions  are  the  same  as  already  described. 
In  the  exudative  forms  the  characteristic  lesions  are  present ;  the 
diphtheritic  naembrane  as  in  diphtheria,  the  croupous  in  that  form 
of  inflammation. 

There  are  other  forms  of  vaginitis  mentioned  by  some  autliors, 
but  they  are  peculiar  in  regard  to  causation,  while  in  their  pathol- 
ogy they  do  not  differ  materially  from  those  described. 

Symptomatology. — The  syuiptoms  in  the  acute  form  are  a  feeling 
of  internal  heat  and  fullness.  These  increase  in  inten&ity,  and  pain 
in  the  vaijina  and  utenis  come  on.  Vesical  and  rectal  tenesmus  are 
present  in  severe  cases,  and  urination  and  defecation  ai-e  painful. 
The  urine  causes  violent  smarting  of  the  inflamed  parts  about  the 
vulva  with  which  it  comes  in  contact.  So  severe  is  the  pain  in  some 
cases  during  and  after  mination,  that  the  patient  resists  the  inclina- 
tion until  the  power  of  evacuation  is  lost,  and  there  is  retention. 

There  are  constitutional  disturbances  also.  At  first  there  is  fever, 
and  following  that  loss  of  apjietite  and  debility.  The  discharge  is 
profuse,  and  sero-pumlent  in  character ;  it  causes  excoriation  of  the 
external  parts,  which  often  extends  to  the  limbs.  If  great  cleanli- 
ness is  not  observed,  the  discharge  decomposes  and  causes  a  very  dis- 
agreeable odor. 

In  the  subacute  and  chronic  fonns  of  vaginitis  the  symptoms 
are  the  same  in  character,  but  less  in  degree ;  in  fact,  the  annoy- 


DISEASES   OF  THE   VAGINA.  107 

iiig  discharge  is  the  only  symptom  observed  in  many  of  these  mild 
cases. 

riiysical  /S/fjiis. — By  inspection  of  the  jiarts  when  the  labia  are 
separated  the  characteristic  discharge  can  be  seen  and  recognized. 
It  differs  from  that  of  vulvitis  in  being  less  tenacious.  The.  nmcous 
glands  about  the  vulva  give  to  the  discharge  of  vulvitis  a  cohesive- 
ness  which  is  not  foimd  in  that  of  vaginitis.  The  use  of  Siras's 
speculum  will  show  the  inllamecl  ajipearance  of  the  membrane  and 
the  discharge  which  is  present. 

The  anterior  and  lateral  portions  only  of  the  walls  of  the  vagina 
are  seen  through  the  Sims  speculum,  but  by  watching  the  folding 
together  of  the  posterior  and  anterior  walls,  as  the  speculum  is  with- 
drawn, the  whole  canal  can  be  thoroughly  inspected. 

The  difference  between  the  signs  of  acute  and  sub-acute  inflam- 
mation is  simply  in  the  intensity  of  the  congestion,  the  extent  of  the 
canal  involved,  and  the  quantity  and  character  of  the  discharge. 

To  distinguish  gonorrhoeal  vaginitis  from  the  non-specific  fonns 
the  microscope  alone  is  suflBcient.  When  there  is  a  question  regard- 
ing the  nature  or  the  cause,  specimens  of  the  discharge  should  be 
examined  for  the  gonococci. 

Causation. — There  is  a  predisposition  to  vaginitis  in  those  of 
delicate  health  and  strumous  diathesis,  but  it  is  not  marked. 

Judging  from  my  own  observations,  the  common  causes  of  vagi- 
nitis are  gonorrhoeal  virus,  metritis,  especially  puerperal,  and  ery- 
thematous affections.  This  applies  to  the  acute  foi'm  of  the  affec- 
tion. 

Sub-acute  and  clironic  vaginitis  may  be  caused  by  any  inflam- 
mation in  the  neighborhood  of  the  canal.  Dysentery,  for  example, 
causes  vaginitis  not  infrequently.  Different  fungi  have  been  credited 
with  causing  vaginitis,  but  this  is  not  well  settled.  When  it  occurs 
in  connecti(ju  with  the  eruptive  diseases  the  cause  is,  of  course,  the 
specific  morbid  material  which  produces  the  constitutional  disease. 

Prognosis. — With  proper  care  vaginitis  can  be  arrested  and  re- 
covery secured  without  any  permanent  lesions.  It  is  liable  to  re- 
cur if  caused  by  gonorrhoea. 

Sometimes  permanent  damage  is  done  to  the  canal  when  the 
vaginitis  is  due  to  any  of  the  eruptive  diseases  or  diplitheria. 

Treatment. — In  the  past,  treatment  of  vaginitis  has  consisted 
mainly  of  the  frequent  use  of  medicinal  douches.  The  agents  used, 
and  the  means  and  ways  of  using  them,  have  varied  greatly  with 
different  practitioners.  Yery  recently  a  new  method  of  treatment 
has  been  brought  to  the  notice  of  the  professi(m  by  Dr.  Engelmann, 


lOS  DISEASES   OF    WoMKX. 

of  St.  Louis.  His  nietliod  he  terms  the  (h-y  treatment,  which  consists 
in  the  use  of  medicinal  jxnvders  and  medicated  tampoiiB.  A  number 
of  veal's  ago  I  ti-ied  this  method,  in  an  imperi'cct  aiid  limited  way, 
in  the  treatment  of  vaginitis  among  the  insane,  and  obtained  ex- 
perience, enough  to  know  that  it  is  of  great  value.  1  lind  even  now, 
however,  that  while  using  certain  agents  in  powdered  form,  and  also 
the  tam))on,  the  discharge  from  the  inflammation  and  the  powder 
used  lodge  in  the  folds  of  the  mucous  membrane,  and  that  it  is 
necessary  to  use  a  vaginal  douche  occasionally  in  order  to  make  the 
treatment  effective. 

In  acute  vaginitis  T  employ  what  may  be  called  a  mixed  treat- 
ment, using  the  medicinal  agents  and  j)owder  with  tampim,  and  oc- 
casionally employing  the  douche  in  the  following  way :  After  cleans- 
ing the  mucous  membrane  thoroughly  with  a  douche  of  wann  water 
and  borax,  a  drachm  to  the  quart,  1  then  thoroughly  apply  sub- 
nitrate  of  bismuth  and  prepared  chalk,  equal  parts,  and  introduce  a 
tampon  of  borated  cotton,  the  tampon  l)eing  so  arranged  as  to  thor- 
oughly keep  the  vaginal  walls  apart;  at  the  end  of  twenty-four  houi-s 
the  tampon  is  removed,  and  any  accumulation  of  the  discharge  and 
powder  is  thoroughly  removed  and  the  tampon  replaced.  At  the 
end  of  the  next  twenty-four  hours  the  tampon  is  removed  and  the 
douche  of  borax  and  water  employed,  and  the  dry  treatment  i-e- 
peated. 

In  acute  cases  where  there  is  much  pain,  and  especially  if  due 
to  specific  cause,  I  employ  iodoform  in  place  of  the  bismuth.  If 
the  trouble  does  not  yield  promptly  to  this  treatment  I  give  up  the 
dry  dressing,  and  every  third  day  apply  to  the  entire  canal,  by  means 
of  the  atomizer  with  strong  pressure,  a  solution  of  nitrate  of  silver, 
one  grain  to  the  ounce,  or  sulphate  of  zinc,  one  half  grain  to  the 
ounce.  I  find  that  such  mild  solutions,  applied  with  considerable 
force  with  the  atomizer,  diffuse  the  application  very  thoroughly,  and 
l^roduce  a  far  more  marked  effect  than  much  stronger  solutions  used 
as  a  douche. 

The  method  of  application  or  sprapng  the  canal  is  as  follows : 
A  Sims's  speculum  is  introduced,  and  when  the  canal  is  distended 
by  pressure,  the  spray  is  thoroughly  a]>j)lied  to  the  upper  portion  of 
the  canal  and  to  the  anterior  and  lateral  walls,  and  the  posterior  wall 
is  sprayed  as  the  speculum  is  gradually  withdraMni.  In  the  inter- 
vening days  between  these  ap})lications  I  employ  daily,  or  t\\'ice  a 
day,  a  vaginal  douche  of  a  solution  of  sulphate  of  zinc,  sixty  grains 
to  the  quart  of  warm  water. 

In  cases  that  can  not  be  so  cai-efully  watched  and  treated,  I  rely 


DISEASES   OF   THE    VAGINA.  109 

almost  wholly  upon  the  sulphate-of-zinc  solution,  used  as  a  vaginal 
douche  twice  a  day  at  first,  and  subsequently  once  a  day.  This  an- 
swers remarkably  well  in  a  great  majority  of  cases,  but  there  is  a 
constant  liability  to  miss  a  portion  of  the  canal,  especially  the  u})per 
and  posterior  fornix.  To  overcome  this,  an  application  of  the  nitrate 
of  silver  or  sulphate  of  zinc  is  to  be  made  to  these  neglected  parts 
once  or  twice  a  week  through  the  speculum. 

This  simple  treatment  is  usually  sufficient  in  all  ordinary  cases, 
but  whenever  the  disease  is  specihc  in  its  origin,  and  is  complicated 
with  urethritis  and  endometritis,  then  these  affections  should  be 
treated  simultaneously  in  the  ordinary  way. 

If  treatment  is  neglected  or  discontinued  too  soon,  the  vaginitis 
will  recur  in  a  very  short  time. 

Vaginismus. — Since  the  time  when  Sims  first  described  this  affec- 
tion and  its  treatment,  it  has  been  considered  by  most  writers  as  a 
distinct  affection,  and  is  usually  classed  as  a  neurosis  of  the  vagina 
or  hymen.  In  all  the  cases  which  have  come  under  my  observation 
the  trouble  has  been  due  either  to  some  affection  of  the  muscles  of 
the  pelvic  floor,  or  to  a  hyperaesthesia  of  the  mucous  membrane  of 
the  vagina.  The  foniier  has  already  been  spoken  of  in  connection 
with  injuries  of  the  pelvic  floor. 

Ilypergesthesia  due  to  affections  of  the  other  pelvic  organs,  I  have 
always  looked  upon  as  a  symptom  of  the  preceding  disease  of  the 
utei-us,  rectum,  or  bladder.  Yiewing  the  subject  from  this  stand- 
point, httle  need  be  said  about  it  in  this  connection.  The  removal 
of  the  affections  which  give  rise  to  it  is  the  chief  indication,  and  is 
generally  sufficient  in  the  way  of  treatment. 

Occasionally,  it  is  necessary  to  give  relief  while  the  treatment  is 
being  employed  to  remove  the  cause ;  and,  in  those  cases  in  which 
the  cause  can  not  be  removed,  efforts  should  be  made  to  reheve  the 
hyperiesthesia.  This  can  usually  be  done  by  the  judicious  use  of 
cocaine. 

Neoplasms  of  the  Vagina. — Many  of  the  neoplasms  of  the  vagina 
are  the  same  in  character  as  those  found  elsewhere ;  as,  for  example, 
sarcoma,  carcinoma,  fibroma,  and  lipoma.     All  these  ai'e  very  rare. 

The  diagnosis  and  treatment  of  these  neoplasms  are  based  upon 
the  same  principles  as  those  w^hich  guide  the  jiractitioner  in  dealing 
with  such  affections  when  located  in  other  parts  of  the  body. 

I  will,  however,  give  a  brief  account  of  some  of  the  more  com- 
mon neoplasms  of  the  vagina  : 

Cysts  of  the  Vagixa. — These  vary  in  size  from  that  of  a  buck- 
shot to  that  of  a  child's  head — one  case,  at  least,  being  on  record. 


110  DISEASES   OK    WOMEN. 

ill  which  the  tiiiuor  was  of  the  latter  size,  and  so  seriousl}'^  interfered 
witli  labor  as  to  necessitate  the  evacuation  of  its  contents  before  the 
labor  could  proceed.  The  contents  of  these  cysts  are  fluid,  of  a  color 
which  may  be  yellowish,  reddish,  or  greenish.  Nelaton  reported  a 
case  in  which,  on  analysis,  the  cyst  contents  were  found  to  be  made 
up  of  water,  eighteen  parts ;  albumen,  one  part  and  a  half  ;  and 
salts,  a  half-part.  Microscopical  examination  has  shown  the  presence 
of  epitlielium,  pus,  cholesterine,  nucleated  and  lymphoid  cells  in 
these  cysts. 

AVinckel,  who  has  examined  these  cysts  with  great  care,  states 
that  their  walls  are  made  up  as  follows :  The  external  surface  is 
covered  with  the  ordinary  pavement  epithelium  of  the  vagina ;  the 
thickness  of  the  walls  varies  between  one  twenty-fifth  and  two  tifths 
of  an  inch — the  thinnest  portion  being  formed  of  connective  tissue 
alone,  the  thicker  with  the  addition  of  smooth  nmscular  libers.  The 
internal  surface  is  usually  perfectly  smooth,  but  may  show  papillae 
covered  with  epitlielium,  which  in  the  majority  of  cases  is  cylindri- 
cal, more  rarely  simple,  or  stratified  pavement  epithelium,  or  still 
more  rarely,  stratihed  pavement  and  cylindrical  epithelium  in  the 
same  cyst. 

These  cysts  of  the  vagina  are  caused  in  some  cases  by  a  closing 
and  subsequent  distention  of  the  vaginal  glands.  They  may  also  be 
due  to  dilated  lymph-vessels,  to  oedema,  and  to  the  accumulation  of 
blood  after  an  injury.  Cysts  may  also  have  their  origin  in  AVolff's 
or  Gartner's  canals  and  in  Miiller's  ducts.  It  is  probable  that  cysts 
of  the  vagina  are  more  common  than  is  generally  supposed.  Their 
recognition  is  not  difficult,  provided  that  a  careful  inspection  is  made 
of  the  vaginal  canal.  Their  treatment  is  exceedingly  simple.  It 
consists  in  emptying  them  by  an  incision  through  their  walls.  To 
prevent  their  refilling,  a  portion  of  the  wall  may  be  cut  out,  and  the 
interior  of  the  cyst  painted  with  the  tincture  of  iodine. 

Fibroma,  Myo:ma,  and  Fibkomyoma. — These  growths  occur  but 
rarely.  Like  the  cysts  of  which  I  have  already  spoken,  they  vary 
very  much  in  size ;  some  being  so  small  as  only  to  be  recognized  by 
the  most  careful  examination,  while  others  mav  be  so  lare:e  as  to  in- 
terfere  seriously  with  micturition  or  defecation,  or  even  to  so  dimin- 
ish the  caliber  of  the  pelvic  canal  in  pregnant  women  as  to  prevent 
the  deliveiy  of  the  child  through  the  natural  passage,  and  to  necessi- 
tate laparotomy.  These  tumors  are  readily  recognized  by  their  den- 
sity. If  there  is  any  doubt  in  the  mind  of  the  practitioner,  an  aspi- 
rating needle  will  at  once  exclude  a  cyst  or  an  abscess.  If  the  tumor 
attains  any  considerable  size  so  as  to  interfere  with  any  of  the  func- 


DISEASES   OF   THE   VAGINA.  HI 

tions  it  should  be  removed,  or  if,  though  small,  it  is  increasing  in 
size,  this  would  constitute  sufficient  indication  for  its  removal.  This 
may  be  done  by  Paquelin's  cautery,  if  the  tumor  is  sufficiently  pedun- 
culated, or  if  not,  it  may  be  enucleated. 

Sarcoma. — This  is  so  rare  as  to  need  but  the  simple  mention. 
Its  treatment  would,  of  course,  be  prompt  removal  as  soon  as  recog- 
nized. 

Carcinoma. — All  that  I  think  it  necessary  to  say  on  this  subject 
has  been  said  in  the  chapter  on  cancer  of  the  uterus,  to  which  the 
reader  is  referred. 


CHAPTER    VI r. 


INJUKIES    TO    THE    PELVIC    FLOOR    FROM    PARTURITION' 

CAUSES. 


A  XI)  othp:r 


In  order  to  comprehend  fully  the  nature  of  the  injui-ies  to  the 
pelvic  floor  and  then*  varied  and  important  pathological  relations,  it 
is  necessary  to  review  hriefly  the  anatomy  and  physiology  of  this 
structure. 

The  pelvic  floor,  which  is  also  known  by  the  somewhat  indefinite 
name  of  perina?um,  comprises  the  tissues  which  together  occupy  the 
space  between  the  bones  of  the  pelvic  outlet.  It  is  composed  of 
muscles,  fascia,  areolar  and  elastic  tissues.  The  muscles,  which 
are  the  chief  element  in  the  stnicture  and  perform  its  function, 
have  their   origin    from   the   iischium,  the  pubes,  and  the  coccyx. 

From  these  points  they  extend  down- 
ward, inward,  and  backward  to  the 
median  line,  and  are  united  to  the 
terminal  ends  of  the  rectum  and  va- 
gina and  to  each  other  from  the  op- 
posite sides. 

The  levator-ani  muscle  arises  from 
the  posterior  surface  of  the  os  j)ubis, 
the  pelvic  fascia,  and  the  s])ine  of 
the  ischium.  It  passes  downward, 
backward,  and  inward,  to  be  inserted 
at  the  following  points :  in  the  me- 
dian line,  the  walls  of  the  vagina  and 
rectum,  its  fellow  of  the  opposite 
side,  and  the  end  of  the  coccyx.  Fig. 
62  shows  the  ])osition  and  attachment 
of  this  muscle. 

The  transversus-perinnei    muscle 
arises  fi'om  the  spine  of  the  ischium,  and  passes  across  to  the  median 


Fig.  62. — The  levator  ani,  seen  from 
witliout  after  removal  of  part  of 
the  liip-hone  (after  Luschka).  a, 
anal  oj)cninrj,  with  sphincter ;  v, 
va"iiia. 


INJURIES   TO   THE   PELVIC   FLOOR. 


113 


line,  wlicre  it  joins  its  fellow  of  the  opposite  side.  This  muscle  fills 
u])  part  of  the  space  left  uncovered  by  the  levator  ani.  The  coccj- 
geiis  arises  from  the  spine  of  the  ischimn,  and  is  inserted  into  the 
side  of  the  lower  part  of  the  sacrum  and  side  and  front  of  the  coc- 
cyx. It  is  understood,  of  course,  that  there  are  two  of  each  of  the 
nmscles  thus  far  described,  one  on  each  side — although  the  two  parts 
of  the  levator  ani  may  be  considered  as  one  because  they  act  as  one 
muscle.  The  same  may  be  said  of  the  transversus-perinsei  muscle. 
The  buibo-caverno- 
sus  muscle  can  be 
most  easily  traced  by 
taking  as  its  origin 
the  space  between 
the  sphincter  ani  and 
the  orifice  of  the 
vagina.  From  this 
point  its  two  halves 
pass  upward,  one  on 
each  side  of  the  vagi- 
na. The  upper  an- 
terior end  of  each 
slip  of  muscle  di- 
vides into  three  parts, 
which  are  inserted  as 
follows  :  One  into  the 
lower  surface  of  the 
corpus  cavernosum  of 
the  clitoris,  a  second 
into  the  posterior  por- 
tion of  the  bulb,  and 
the  third  unites  with 
its  fellow  of  the  op- 
posite side  in  the  mucous  membrane  of  the  vestibule ;  and  all  of 
them  are,  through  the  medium  of  tendon  and  fascia,  connected  to 
the  pubic  bones.  If  this  muscle  is  traced  from  above  downward 
to  the  center  of  the  pelvic  floor,  it  will  be  seen  to  have  an  origin 
and  insertion  like  that  of  the  anterior  fibers  of  the  levator  ani ; 
hence  the  bulbo-cavernosus  and  levator  ani  may  be  considered  as 
one  muscle.  This  view  is  justifiable  from  the  fact  that  they  also 
contract  together,  having  a  similar  function. 

All  of  these  muscles  have  one  feature  in  common,  and  that  is, 
the  blending  of  their  fibers  from  the  opposite  sides  of  the  pelvic 
9 


Fig.   63. — The  muscles  of   the  pelvic  floor  (after  Hart  and 
Savage). 


114:  DISEASES   OF    WOMEN'. 

outlet,  and  their  attacliment  to  the  terminal  ends  of  the  rectum  and 
vagina. 

The  Kphiiicter-uni  muscle,  which  liius  a  function  peculiarly  its 
own,  is  closely  united  to  all  the  other  muscles  of  the  pelvic  floor  by 
an  interlacintj  of  the  muscular  fibers  and  by  tendinous  and  fascial 
attachments.  This  muscle  arises  from  the  end  of  the  coccyx,  and 
surrounds  the  end  of  the  rectum  in  conjunction  with  its  circular 
fibers,  while  some  of  its  deeper  fibers  are  attached  to  the  tissues  in 
the  median  line  between  the  rectum  and  vagina.  The  superficial 
fibers  of  this  muscle  are  circular,  and  attached  to  the  integument 
like  all  tnie  sphincteric  muscles. 

Taking  the  muscles  of  the  pelvic  floor  in  the  aggregate,  they 
form  one  complete  diaphragm  of  muscular  tissue  which  fills  the  pel- 
vic outlet.  By  this  arrangement  the  rectum  and  vagina  are  held  in 
position,  and  their  tenninal  ends  controlled  in  the  performance  of 
their  functions.  The  muscular  attachment  of  the  muscles  and  va- 
gina is  in  part  shown  by  the  preceding  Figures  02  and  63. 

The  normal  elevation  of  the  pelvic  floor  is  illustrated  by 
Fig.  64. 

This  position  of  the  pelvic  floor  and  the  relations  of  the  rectum 
and  vagina  should  be  noted  because  they  become  changed  in  most 
of  the  injui-ies  of  this  structure. 

The  muscles  of  the  pelvic  floor  are  surrounded  by  the  deep  and 
superficial  fascia,  which  in  some  parts  become  ligamentous  in  char- 
acter ;  for  example,  the  ischio-perineal  ligament — that  dense  portion 
of  the  fascia  which  stretches  from  one  side  to  the  other  through  the 
space  between  the  rectum  and  vagina.  This  fascial  structure  accom- 
panying the  muscles  is  characteristic  of  all  muscular  structures  which 
have  to  afford  continuous  sustaining  power,  like  the  muscles  of  the 
back,  of  the  neck,  abdomen,  and  thigh. 

jF\mction.—^These  anatomical  facts  regarding  the  floor  of  the  pel- 
vis suggest  that  its  functions  are  to  sustain  the  rectum  and  vagina, 
and  to  aid  in  their  functions.  The  arrangement  of  the  muscles  is 
such  that  they  clos3  by  sphincteric  action  the  terminal  ends  of  the 
rectum  and  vagina,  3'et  also  permit  the  distention  of  their  orifices 
during  the  acts  of  parturition  and  evacuation  of  the  rectum.  When 
pressure  is  made  downward  by  any  body  in  the  rectum  or  vagina, 
the  perineal  muscles  act  to  draw  the  orifices  of  these  canals  upward, 
and  hence  supply  a  resisting  force  to  the  downward  pressm'e  which 
effects  dilatation  of  the  vagina  and  rectum.  This  action  of  the  mus- 
cles in  resisting  downward  pressure  is  well  demonstrated  during  par- 
turition.    When  the  child's  head  presses  upon  the  floor  of  the  pel- 


INJURIES  TO  THE   PELVIC   FLOOR.  115 

vis,  the  muscles,  by  retraction,  distend  tlie  sphincter  ani  to  a  great 
extent.     The  dilatation  of  the  vagina  is  produced  by  a  more  passive 


Fig.  64. — Diagrammatic  sagittal  section  of  the  female  pelvis,  u,  uterus ;  r,  rectum  ;  s, 
symphysis;  p,  perineal  body  ;  b,  is  beneath  bladder.  This  is  the  position  of  the 
uterus  when  the  bladder  is  almost  empty. 

giving  way  to  the  forces  above,  and  yet  the  muscles  exert  a  well- 
defined  power  in  retracting  that  portion  of  the  pelvic  floor.  This 
function  of  the  muscles  should  be  noted  because  it  enters  into  the 
mechanism  of  most  of  the  injuries  to  be  discussed. 

This  brief  statement  regarding  the  function  of  the  pelvic  floor 
embodies  the  essential  points  in  its  chief  offices.  There  remains 
something  to  be  said  regarding  its  relations  to  the  pelvic  organs. 

Up  to  the  present  time  the  attention  given  to  this  subject  by 
gynecologists  has  been  almost  wholly  confined  to  laceration  of  the 
so-called  perineal  body — an  injury  frequently  seen,  but  not  by  any 
means  the  only  one  that  occurs  to  these  parts.  This  concentration 
of  attention  on  one  portion  of  the  subject  has  given  rise  to  great 


110  DISEASES   OF   WOMEN. 

diversity  of  opinions  regarding  the  function  of  tlio  perinaeum  and 
its  relations  to  the  displacements  of  the  pelvic  organs,  one  party  to 
the  controversy  believing  that  the  perineal  body  has  much  to  do 
with  sustaining  the  pelvic  organs  in  position,  the  other  holding  that 
it  has  very  little  power  in  this  respect.  AVithout  summing  up  at 
great  length  the  arguments  on  both  sides,  the  facts  bearing  on  the 
practical  side  of  the  subject  may  be  briefly  stated. 

In  all  injuries  of  the  pelvic  floor  which  impair  its  supporting 
function  to  any  extent,  prolapsus  of  the  pelvic  organs  will  follow  in 
time,  except  in  three  conditions : 

1.  When  the  injury  is  compensated  for  by  the  muscles  (which 
still  maintain  their  attachment  to  the  vagina  and  rectumj  drawing 
the  remaining  portion  of  the  pelvic  floor  upward,  forward,  and 
toward  the  pubes,  thereby  closing  the  vaginal  orifice  and  supporting 
the  pelvic  organs. 

2.  Wliere  by  reason  of  some  intra-pelvic  inflammation  the  organs 
have  become  flxed  by  adhesions ;  and, 

3.  Where  the  patient  is  abundantly  supplied  \vith  adipose  tissue, 
and  takes  very  little  active  exercise. 

Excepting  under  the  circumstances  liere  named,  prolapsus  of  the 
pelvic  organs  invariably  occurs  after  important  injuries  of  the  pelvic 
floor.  The  displacement  does  not  follow  the  injury  immediately, 
but,  as  a  rule,  comes  on  slowly.  This  conclusion  has  been  arrived  at 
from  a  large  number  of  clinical  observations,  and  it  helps  to  definite- 
ly settle  the  question  regarding  the  value  of  tlie  pelvic  floor  as  a 
means  of  support  for  the  ])elvic  organs.  From  these  facts  one 
may  obtain  the  key  to  the  differences  of  opinion  which  have  been 
held  by  gynecologists  regarding  the  functions  of  the  pelvic  floor. 
Those  who  believe  that  it  plays  a  secondary  part  in  maintaining  the 
pelvic  organs  in  position  argue  that  there  are  anatomical  structures 
which  sustain  the  pelvic  organs  in  place  without  aid  from  the  pel- 
vic floor,  and,  in  proof  of  this,  point  to  the  fact  that  the  removal 
of  the  pelvic  floor  is  not  followed  by  displacement  of  the  pelvic  or- 
gans. This  is  often  seen  in  cases  in  which  lacerations  sufficient 
to  largely  impair  the  function  of  the  pelvic  floor  have  existed  for 
•  years  in  women  in  active  life  without  the  occurrence  of  prolapsus 
of  the  pelvic  organs.  And,  more  than  all  this,  it  is  said,  prolapsus 
of  the  peine  organs  occui's  where  there  is  no  apparent  injury  of 
the  pelvic  floor — i.  e.,  no  laceration  of  the  perinanim.  The  falla- 
cies of  this  argument  are  that,  although  the  pelvic  organs  are 
held  in  position  by  supports  that  are  sutflcient  to  resist  ordinary 
taxation  for  a  given  time,  they  are  not   able  to  do  so  under  ex- 


INJURIES   TO   THE   PELVIC   FLOOR.  117 

traordinary  pressure  for  any  length  of  time  unaided  by  the  pelvic 
floor. 

Again,  the  cases  cited  in  which  prolapsus  does  not  occur  while 
the  periuiieum  is  lacerated  belong  to  one  or  another  of  the  three  ex- 
ceptional states  which  I  have  already  given. 

And,  finally,  the  cases  in  which  there  is  prolapsus  while  the  pelvic 
floor  appears  to  be  uninjured  are,  as  a  rule,  cases  of  mistaken  diag- 
nosis, the  floor  of  the  j^elvis  being  really  imperfect,  although  not 
apparently  so  on  examination  by  the  sense  of  sight  alone.  Some 
observers  look  for  a  laceration  of  the  perinseum  by  inspection  of  its 
mucous  and  tegumentary  surfaces,  and,  if  injury  to  these  surfaces  is 
not  found,  they  pronounce  the  pelvic  floor  perfect,  while  the  fact  is 
that  laceration  of  the  periuseum  in  the  median  line  is  only  one  of 
many  injuries  of  the  pelvic  floor  which  render  it  functionally  imper- 
fect. But  granting  that  the  pelvic  floor  takes  no  part  in  supporting 
the  pelvic  organs  under  ordinary  taxation,  it  certainly  aids  in  doing 
so  in  case  there  is  extraordinary  downward  pressure  from  lifting 
heavy  weights,  violent  coughing,  and  the  like.  Again,  when  the 
pelvic  floor  is  injured — say  by  laceration — and  loses  the  power  to 
support  itself  and  the  vagina  and  rectum,  prolapsus,  especially  of  the 
vagina,  occurs.  This  causes  a  dragging  upon  the  pelvic  organs  which 
in  due  time  will  cause  them  to  descend.  In  view  of  these  well-- 
known  facts,  the  most  enthusiastic  advocate  of  the  independent  sup- 
ports of  the  pelvic  organs  must  admit  that  the  pelvic  floor  is  at  least 
indirectly  concerned  in  supporting  the  structures  above  it. 

Varieties. — The  injuries  of  the  pelvic  floor  usually  seen  in  prac- 
tice are : 

1.  The  various  degrees  of  laceration  of  the  peringeum,  i.  e.,  in 
the  median  line  of  the  pelvic  floor. 

2.  Subcutaneous  separation  of  the  muscles  of  the  pelvic  floor  at 
their  junction  in  the  median  line,  or  so-called  perineal  body; 

3.  Laceration  in  the  median  line,  and  temporary  loss  of  power  in 
the  remaining  muscles  from  overdistention. 

4.  Laceration  of  the  levator-ani  muscle,  occurring  alone  or  accom- 
panied by  the  lesions  already  given. 

5.  Atrophy  and  permanent  paralysis  from  injuries  during  partu- 
rition and  other  causes. 

6.  Loss  of  muscular  motion  caused  by  the  products  of  foi'mer 
inflammation. 

The  first  of  these,  laceration  in  the  median  line  of  the  pelvic 
floor,  is  the  injury  most  frequently  sustained  during  parturition. 
Several  degrees  of  this  injury  are  described  by  authors,  but  in  re- 


lis  DISEASES  OF  WOMEN. 

gai'il  to  the  pathology  and  treatment  there  are  only  two  which,  in 
this  connection,  require  attention :  the  one  which  extends  through 
the  muscles  of  the  anterior  portion  of  the  pelvic  floor — that  is,  from 
the  vulva  to  the  sphincterani  muscle,  and  the  other  which  extends 
through  the  sphincter-ani  muscle  and  into  the  rectum.  The  former 
of  these  is  the  injury  which  is  most  frequently  recognized,  and  is 
therefure  presumed  to  occur  most  frequently,  although  this  point  is 
not  yet  settled.  Certainly  it  is  the  least  grave  in  its  consequences  if 
j)roperly  cared  fci',  because  it  is  the  most  easily  remedied  hy  surgical 
treatment. 

In  its  simplest  form  the  laceration  extends  through  the  mucous 
memlmane  of  the  vagina,  the  integument,  and  the  junction  or  union 
of  the  bulbo-cavernosus  with  the  transversus-periuii^i  muscle,  a  few 
fibers  of  the  levator  aul  anrl  the  fascia,  elastic  and  areolar  tissues 
which  constitute  the  perineal  bf)dy. 

When  this  injury  is  uncomplicated  with  laceration  of  the  muscles 
of  the  pelvic  floor  elsewhere  than  at  the  median  line,  the  separated 
ends  of  the  muscles  involved  in  the  rupture  still  retain  their  union 
with  the  divided  side  of  the  perineal  l)ody  and  with  each  other.  This 
is  very  clearly  shown  by  the  fact  that  the  bulbo-cavernosus,  trans- 
versus  perintei,  and  anterior  flbers  of  the  levator-ani  muscles  hold 
the  separated  sides  of  the  perineal  body  and  the  posterior,  uninjured 
portion  of  the  pelvic  floor  upward.  At  the  same  time  that  the  pos- 
terior portion  of  the  pelvic  floor  is  maintained  at  its  normal  eleva- 
tion, it  is  often  brought  forward  to  compensate  for  the  loss  of  sup- 
port caused  by  the  laceration  (Fig.  65).  This  compensation  does 
not  occur  in  all  cases,  but  usually  does  so  unless  there  is  damage 
done  to  the  muscles  other  than  at  the  median  rupture  alone.  I  have 
observed  in  some  cases  sufiicient  drawing  forward  to  lessen  the  dis- 
tance between  the  meatus  nrinarius  and  anus  very  perceptibly.  This 
is  familiar  to  all  who  have  studied  the  subject  with  a  view  to  operat- 
ing, from  the  fact  tliat,  in  order  to  estimate  the  depth  of  the  lacera- 
tion, to  determine  how  extensive  the  vi-s-ifying  of  tissue  need  be,  it 
is  necessary  to  retract  the  posterior  portion  of  the  pelvic  floor  with 
the  finger  or  sound  in  order  to  press  the  rectum  or  aims  backward 
into  its  place.  This  compensation  ]>revents  prolapsus  of  the  pelvic 
organs  for  a  long  time,  in  some  cases  for  many  years,  and  is  one  rea- 
son why  rupture  of  the  perineal  body  is  not  always  followed  by  pro- 
lapsus uteri.  In  this  condition  the  vidva  is  not  enlarged  from  dis- 
tention by  the  partially  inverted  vaginal  walls,  nor  is  the  uterus 
necessarily  displaced.  Many  such  eases  axe  seen  among  patients 
who  seek  relief  for  other  affections,  but  have  no  symptoms  which 


INJURIES   TO   THE   PELVIC    FLOOR. 


119 


can  be  traced  to  the  laceration,  except  occasional  paiii  in  the  scar 
tissue  in  the  injured  part. 

Case. — Mrs.  H.,  aged  forty,  had  had  six  children.     During  her 
first  labor  she  says  she   was  "  torn,"  the  child  weighing  thirteen 


Fig.  65. — Complete  laceration  of  the  periuEeum;  anus  drawn  i'orwaid  ;  no  rectoeele. 

pounds.  Of  the  perineal  body  a  part  of  the  anal  sphincter  alone  re- 
mains ;  but  a  little  way  up  the  posterior  vaginal  wall  a  thick,  strong, 
muscular  band  crosses,  which  tightens  about  the  examining  finger 
and  draws  the  anus  forward.  The  uterus  is  in  place,  and  there  is  no 
rectoeele  ;  nor  sagging  of  the  pelvic  floor ;  nor  are  thei'e  symptoms. 
(See  Fig.  65.) 

Rupture  through  the  sphincter  ani  is  the  most  unfortunate  of  all 
injuries  of  the  pelvic  floor,  owing  to  the  incontinence  which  follows. 
The  unhappy  subjects  of  this  accident  are  debarred  from  taking 


120  DISEASES   OF    WOMEN. 

imicli  active  exercise,  and  usually  avoid  society.  Strange  afi  it  may 
appear,  they  do  not  all  suffer  from  |)rolapsus  of  the  pelvic  organs; 
in  fact,  1  think  that  prolapsus  following  this  injury,  to  any  great 
degree  at  least,  is  the  exception.  This  is,  no  doubt,  due  to  the  fact 
that  such  patients  are  unable  to  do  much  walking  or  standing,  and 
therefore  the  pelvic  organs  are  not  submitted  to  much  downward 
pressure.  It  might  be  supposed  that  relief  from  this  distressing  con- 
dition would  be  sought  before  sufficient  time  had  elai)sed  for  prolai> 
sus  to  occur,  but  this  is  not  always  the  ca.se,  for  I  have  seen  several 
such  injuries  of  many  years'  standing,  and  yet  there  was  very  little 
displacement.  There  is  indeed  very  little  falling  of  the  pelvic  floor 
or  of  its  divided  sides.  This  is  accounted  for  by  the  fact  that  the 
laceration  extends  through  the  greater  portion  of  the  pelvic  tioor, 
leaving  little  remaining  to  settle  dowTiward.  In  most  cases  the  two 
halves  of  the  floor  are  held  well  up  in  position  by  the  muscles  which 
are  attaclied  to  them.  When  the  laceration  is  through  the  sphinc- 
ter-ani  muscle  only,  and  does  not  extend  upward  into  the  anterior 
wall  of  the  rectum  and  the  posterior  wall  of  the  vagina,  there  is  a 
little  control  of  the  rectum  still  retained. 

This  retaining  power  is  sometimes  favored  by  a  band  of  scar  tis- 
sue, which  lies  between  the  upper  fibers  of  the  divided  sjihincter, 
and  gives  a  fixed  point  toward  which  the  muscle  can  contract  in  an 
imperfect  way.  There  is  usually  prolapsus  of  the  raucous  metiibrane 
of  the  rectum  in  cases  of  long  standing,  and  the  prolapsus  is  almost 
alwavs  greater  if  the  wall  of  the  vasriua  and  rectum  are  also  lacer- 
ated  to  any  great  extent. 

The  second  form  of  injury  mentioned  in  the  classification  is  sub- 
cutaneous separation  of  the  muscles  of  the  pelvic  floor  at  their  junc- 
tion in  the  median  line,  or  perineal  body.  The  mucous  membrane 
of  the  vagina  and  the  skin  covering  the  perina?um  remain  normal, 
but  tlie  transversus-perinaei  muscles  are  torn  apart  in  the  median 
line.  The  bulbo-cavernosus  muscles  are  separated  from  their  inser- 
tion at  the  center  of  the  perinfcum,  and  possibly  some  of  the  fibers 
of  the  levator-ani  muscle  are  also  lacerated.  There  is,  in  short,  a 
complete  laceration  of  the  deeper  structures  of  the  perinjcum,  the 
skin  and  mucous  membrane  alone  remaining  uninjured.  The  result 
of  this  injury  is  falling  of  the  pelvic  floor,  and  usually  jirulapsus  of 
the  pelvic  organs.  The  function  of  the  pelvic  floor  is  destroyed  as 
completely  as  in  the  injury  first  described. 

I  beheve  that  this  condition  has  frequently  been  mistaken  for 
functional  imperfection  of  the  perinaeum,  or  relaxation,  as  it  has 
been  called.     The  fact  is,  that  it  is  a  well-defined  anatomical  lesion, 


INJURIES  TO  THE  PELVIC  FLOOR.  121 

which  can  be  demonstrated  quite  easily  by  passing  the  finger  into 
the  vagina  and  pressing  downward  and  outward.  In  this  way  the 
absence  of  the  muscles,  fascia,  and  connective  tissue  is  discovered. 
It  is  found  also  by  this  examination  that  all  muscular  resistance  is 
lost  in  the  parts.  Again,  while  the  index-linger  is  in  the  vagina  the 
parts  anterior  to  the  sphincter-ani  muscle  can  be  grasped  between 
the  linger  and  thumb,  which  will  show  that  where  the  perineal  body 
should  be  there  is  only  skin  and  posterior  vaginal  wall.  There  is 
still  another  method  of  examination,  and,  perhaps  the  most  critical 
one — that  is,  to  pass  one  index-finger  into  the  vagina  and  the  other 
into  the  rectum,  when  it  will  be  found  that  tlie  onlj-  resisting  mus- 
cular tissue  felt  betw^een  the  two  fingers  is  the  sphincter  ani. 

These  examinations  by  the  touch  are  quite  sufficient ;  but,  if  fur- 
ther evidence  is  desired,  it  may  be  obtained  by  trying  to  excite  con- 
traction of  the  muscles  which  act  as  a  sphincter  vaginae.  This  can 
be  done  by  the  interrupted  electric  current,  or  by  irritating  the  labia. 
In  making  a  vaginal  examination,  every  one  has  noticed  how  actively 
the  muscles  of  the  pelvic  floor  contract  and  close  the  introitus  vagi- 
nae in  the  normal  state ;  but  in  this  injury  no  such  contraction  oc- 
curs, nor  can  it  be  produced  by  pricking  the  labia  with  a  needle,  or 
any  such  means  used  to  excite  reflex  action. 

In  case  the  levator-ani  muscle  remains  intact,  the  posterior  por- 
tion of  the  pelvic  floor  remains  in  its  normal  position,  except  that  the 
end  of  the  rectum  may  be  displaced  backward,  whicb  it  often  is, 
because  the  vagina  and  uterus  are  prolapsed.  The  counterpart  of 
this  lesion  is  often  seen  in  cases  that  have  been  operated  upon  with 
the  intention  of  restoring  the  pelvic  floor  or  perinpeum,  the  operation 
having  failed  in  its  object.  Union  of  the  skin  and  mucous  membrane 
is  obtained,  but  the  muscles  are  not  united,  and  hence,  although  upon 
removing  tbe  sutures  tbe  result  is  pronounced  to  be  perfect,  and  to 
the  superficial  observer  appears  to  be  so,  the  muscular  function  of 
the  pelvic  floor  has  not  been  restored,  and  the  operation  is,  in  fact,  a 
complete  failure. 

The  third  form  of  injury  given  in  the  classification  presents  tbe 
same  lesions  as  have  been  given  in  describing  the  two  preceding 
forms.  There  is  a  laceration  in  the  median  line  down  to  the  sphinc- 
ter ani,  and  also  an  overstretching  of  the  muscles,  which  give  rise  to 
sagging  of  the  whole  pelvic  fioor  and  backward  displacement  of  tbe 
rectum.  In  some  cases,  in  place  of  overstretching  there  is  retraction 
of  the  ends  of  the  torn  muscles,  so  that  they  have  no  further  connec- 
tion with  the  di^-ided  sides  of  the  perineal  body  or  with  the  sphinc- 
ter ani,  and  hence  they  can  no  longer  sustain  the  pelvic  fioor  even  in 


122  DISEASES   OF    WOMEN. 

ail  imperfect  way,  as  is  observed  iu  cases  of  (simple  laceration  already 
described,  in  Avliich  eoiiipensati(jii  is  made  l)y  tlie  muscles  drawing 
the  posterior  portion  of  the  pelvic  floor  upward  and  forward.  Evi- 
dence of  this  subcutaneous  overdistention  or  retraction  of  the  nius- 
eles  and  temporary  i)aralysis  is  seen  in  a  great  many  cases  of  partu- 
rition. Every  obstetrician  has  observed  the  complete  relaxation  of 
the  pelvic  floor  that  so  frequently  follows  delivery,  even  when  there 
is  no  laceration  of  the  integument.  There  is  not  only  loss  of  mus- 
cular motion,  but  also  loss  of  sensation  in  some  cases.  That  this  re- 
laxation is  due  in  many  cases  to  overdistention  of  the  muscles  with- 
out solution  of  continuity  is  probable  from  the  fact  that  recovery  is 
so  rapid  and  complete.  Still,  in  many  cases  the  injury  done  to  the 
muscles  is  sufficient  to  defy  the  natural  recuperative  ])Owers,  and 
remains  permanent,  if  not  relieved  by  surgical  treatment. 

In  many  of  the  cases  of  this  kind  seen  in  practice  the  muscular 
insufficiency  is  doubtless  caused  by  overdistention  produced  by  pro- 
lapsus of  the  pelvic  organs.  As  soon  as  the  pelvic  organs  descend 
so  as  to  make  continuous  pressure  upon  the  pelvic  floor,  the  muscles 
(impaired  by  the  laceration  in  the  median  line)  gradually  give  way, 
and  finally  lose  their  contractile  power,  either  temporarily  or  perma- 
nently, according  to  the  length  of  time  that  the  prolapsus  has  ex- 
isted. It  follows,  then,  that  it  is  only  when  sagging  of  the  pelvic 
floor  is  seen  before  any  prolapsus  of  the  pelvic  organs  has  taken  place 
that  we  can  reasonably  infer  that  the  muscles  were  impaired  at  the 
time  that  the  laceration  occurred,  and  that  the  injury  was  more  ex- 
tensive than  the  mere  separation  at  the  median  line. 

The  fourth  injury  is  laceration  of  the  levator-ani  nniscle  with  or 
without  being  accompanied  with  the  injuries  which  have  been  de- 
scribed already. 

This  is  the  most  extensive  injury  which  occurs,  and  is  one  of  the 
most  disastrous  of  all  in  its  consequences ;  and  what  gives  it  greater 
importance  is  the  fact  that  it  is  not,  so  far  as  I  know,  conmionly  men- 
tioned in  our  literature.  I  am  satisfied  that  this  injury  to  the  pelvic 
floor  occurs  frequently,  but,  fortunately,  recovery  occurs  many  times 
unaided  by  any  special  treatment.  Still,  there  are  many  cases  in  which 
the  injury  is  permanent,  and  can  not  be  relieved  by  any  treatment 
known  at  the  present  time.  This  condition  may  be  associated  with 
complete  laceration  in  the  median  line,  but  usually  is  not.  I  pre- 
sume that  the  subcutaneous  laceration  of  the  muscles  saves  the  super- 
ficial structures  of  the  perineal  body.  When  there  is  no  laceration 
in  the  median  line  the  tissues  between  the  rectum  and  vagina  appear 
to  be  normal ;  at  least  the  distance  from  the  anus  to  the  posterior 


INJURIES   TO   THE    PELVIC    FLOOR, 


12? 


comuiissnre  of  the  vuii^ina  is  nonual,  bat  tliere  is  loss  of  contractile 
power  in  the  parts.  The  whole  pelvic  iioor,  including  the  rectinn, 
vagina,  and  lower  part  of  the  labia,  projects  downward  below  its 
normal  elevation.  This  suggests  the  thought  that  subcutaneous  lacer- 
ation of  the  transversus  perinsei  generally  takes  place  also  when  the 
levator  ani  is  injured. 

Fig.  (>(*)  shows  the  downward  displacement  resulting  from  the 
injury  to  the  muscles.  This  displacement  can  be  demonstrated  upon 
the  subject  by  placing  one  linger  upon  the  pubes  and  the  other  on 
the  tip  of  the  coccyx,  and  observing  the  extent  to  which  the  pelvic 
Hoor  projects  below  these  two 
points.  Again,  by  placing  the  pa- 
tient upon  the  side  and  flexing  the 
thiohs  at  right  angles  with  the 
trunk,  the  downward  displacement 
becomes  apparent.  In  the  most 
])ronounced  cases  the  parts  project 
downward  almost  on  a  line  with 
the  nates.  The  physical  signs  of 
this  condition  will  be  referred  to 
again  in  connection  with  atrophy 
of  the  muscles,  and  the  differential 
points  will  be  noted. 

Atrophy,  and  the  consequent 
paralysis  from  injuries  during  par- 
turition and  other  causes,  occurs 
only  in  cases  of  long  standing,  and 
is,  in  fact,  a  secondary  state  re- 
sulting from  laceration  of  the  mus- 
cles or  overdistention.  It  may 
follow  any  of  the  injuries  already 


mentioned  that    have    been  long 


Fig.  66.- — Sagging  of  the  pelvic  floor.  The 
sweep  from  a  to  b  denotes  the  sagging 
portion  of  the  pelvic  floor.  The  bulging 
posterior  vaginal  wall  (rectocele)  shows 
white  between  the  labia. 


neglected,  or  in  which  unsuccessful 
efforts  have  been  made  to  over- 
come the  original  injury.  The  muscles,  having  been  torn  or  sepa- 
rated from  their  liganrentous  attachments  during  parturition,  become 
functionally  inactive,  and  remain  so  until  they  undergo  fatty  degen- 
eration and  are  Anally  lost.  These  are  usually  neglected  cases, 
but  the  same  condition  is  seen  when  a  surgical  effort  at  restoration 
has  been  made  which  has  resulted  in  union  of  the  skin  and  mucous 
membrane  without  restoring  the  muscles.  The  same  thing  is  pro- 
duced in  another  way.      The  pelvic  floor  sustains  an  injury,  slight 


124  DISEASES  OF   WOMEN. 

in  itself,  wliicli  is  perinitted  to  reimiin  until  jirolapsus  of  the  pel- 
vic organs  i)r()(hices  overdistention  of  the  muscles,  and  maintains 
it  so  long  that  atrophy  of  the  muecles  takes  j)lace  and  permanent 
loss  of  the  function  of  the  pelvic  floor  follows.  Other  and  rarer 
cases  are  seen  in  which  atroi)hy  of  the  muscles  occurs  as  the  result 
of  long-continued  overdistention.  This  I  have  seen  in  cases  of 
paralysis  caused  by  hypertrophic  elongation  of  the  cervix  uteri 
and  small  tibroids  in  the  uterus.  In  these  cases  there  was  no  evi- 
dence that  the  floor  had  sustained  any  injury  other  than  that  pro- 
duced by  the  prolapsus.  I  am  also  personally  convinced  that  pro- 
lapsus of  the  pelvic  organs  may  be  due  to  injuries  of  the  uterine 
ligaments  'and  upper  pelvic  fascia  while  the  jielvic  floor  sustained  no 
injury  whatever  until  the  prohq^sed  organ  caused  its  overdistention. 
Again,  habitual  constipation  will  cause  ])aralysis  of  the  muscular 
tissues  of  the  rectum,  and  also  (to  some  extent,  if  not  wholly)  of  the 
levator  ani,  and,  if  this  continues  long  enough,  atropliy  and  jierma- 
nent  paralysis  will  follov/.  If  to  this  constipation  prc»lapsus  of  the 
pelvic  organs  is  added,  and  they  both  continue  for  a  long  time,  per- 
manent insufficiency  of  tlie  j^elvic  floor  will  occur  from  nuiscular 
atrophy.  Finally,  I  presume  (though  I  can  not  prove)  that  atrophy 
of  the  muscles  occurs  in  very  old  won'ien  from  no  other  cause  than 
senile  malnutrition.  In  this  state  of  the  parts  other  anatomical  le- 
sions occm'  in  nearly  all  cases.  The  fascia  and  elastic  tissue  are 
wanting,  and  the  blood-vessels — notably  the  veins — become  over- 
distended,  giving  a  well-marked  passive  hyjjeraemia.  The  vast  ditfer- 
ence  in  the  vascularity  noticed  in  operating  in  different  cases  is 
accounted  for  in  this  way. 

The  extent  of  prolapsus  which  occurs  in  tliis  form  of  muscular 
insufficiency  differs.  In  the  most  marked  case  that  I  have  seen  it 
was  so  great  that  the  anus  was  nearly  on  a  line  with  the  nates  while 
the  patient  was  in  Sims's  position.  The  physical  appearance  of  this 
affection  has  been  already  illustrated  in  connection  with  recent  lacer- 
ations— the  fourth  injury  described  (see  Fig.  60).  The  informa- 
tion obtained  by  inspection  is  usually  sufficient  for  a  diagnosis,  but 
still  further  evidence  can  be  obtained  by  the  touch ;  this  shows  the 
lax,  non-resistant  state  of  the  muscles,  which,  as  already  stated,  can 
not  be  excited  to  contraction  by  irritation  or  the  electric  current. 

In  the  diagnosis  of  all  these  injuries,  the  all-important  question 
is  to  determine  whether  the  paralysis  is  due  to  overdistention  of  the 
muscles  and  is  temporary  only,  or  due  to  atrophy,  and  hence  perma- 
nent. This  can  not  always  be  settled  at  once  and  positively.  If  the 
tissues  of  the  pelvic  floor  appear  to  the  touch  to  be  lacking  muscular 


INJURIES   TO  THE  PELVIC   FLOOR.  125 

fiber,  and  no  muscular  contraction  can  be  induced  by  stimnlation,  it 
is  ])resuni})tive  evidence  of  muscular  atrophy  ;  and  yet  it  may  be  only 
a  temporary  loss  of  muscular  power.  It  is  necessary,  then,  to  sup- 
port the  pelvic  floor  and  let  the  patient  rest  in  the  recumbent  posi- 
tion to  remove  all  downward  pressure  from  the  parts,  and,  by  the 
use  of  astringents  and  electricity,  endeavor  to  restore  the  muscular 
function  sufficiently  to  prove  that  there  is  still  nmscular  tissue  pres- 
ent. If  by  such  means,  the  muscular  function  is  even  partially  re- 
stored, the  diagnosis  is  completed,  and  the  indications  for  further 
treatment  are  established.  It  is  then  and  only  then  that  surgical 
treatment  may  be  employed  with  the  hope  of  obtaining  complete 
recovery.  Should  all  well-directed  efforts  fail  to  give  evidence  that 
the  muscles  still  retain  their  true  anatomical  characteristics,  it  is  use- 
less to  hope  for  success  in  operating. 

Symptomatology. — The  symptoms  which  are  developed  by  injuries 
to  the  pelvic  floor  are  not  sufficiently  diagnostic,  or  else  they  have  not 
yet  been  sufficiently  studied,  to  make  them  of  decided  value  to  the 
diagnostician.  Patients  express  a  feeling  of  want  of  support  of  the 
pelvic  organs,  or,  as  they  express  it,  a  dragging-down  feeling,  and 
some  derangement  of  the  fmictions  of  the  rectum  and  bladder,  but, 
as  these  symptoms  occur  in  all  the  forms  of  injury  named,  and  as 
tliey  also  in  like  manner  occur  in  displacement  of  the  pelvic  organs, 
but  little  reliance  can  be  placed  upon  them.  When  the  function  of 
the  levator-ani  muscle  is  lost  from  injury  or  atrophy,  there  is  usually 
much  difficulty  in  evacuating  the  rectum.  This  is,  of  course,  most 
marked  when  the  patient  is  constipated,  but  it  is  noticed  also  when 
the  bowels  are  free,  though  to  a  less  extent.  When  there  has  been 
a  laceration  in  the  median  line  the  scar  tissue  is  often  tender  to  the 
touch,  and  occasionally  causes  some  general  nervous  disturbance. 
The  sensitiveness  of  this  scar  tissue  is  sometimes  so  great  as  to  pro- 
duce reflex  muscular  contraction  when  touched  while  the  patient  is 
anaesthetized.  The  admission  and  expulsion  of  air  from  the  vagina 
(flatus  vaginalis)  is  said  to  occur  frequently  in  these  injuries,  and  it 
is  no  doubt  one  of  the  most  reliable  symptoms  of  injuries  of  the 
pelvic  floor,  as  it  rarely  occurs  in  any  other  condition. 

The  last  of  the  pathological  states  of  this  structure  to  be  described 
is  muscular  rigidity  produced  by  a  previous  inflammation,  the  prod- 
ucts of  which  have  impaired  the  muscular  tissue. 

This  affection  has  been  classed  by  authors  under  the  head  of  rigid 
perineeum,  vaginismus,  and  spasmodic  muscular  contraction,  but  it 
belongs  to  a  different  pathological  order  of  things.  There  are  cases 
of  rigidity  or  spasmodic  contraction  of  the  muscles  due,  perhaps,  to 


120  DISEASES   OF    WOMEN. 

liypenesthesia,  Imt  tlie  condition  under  consideration  is  simply  a 
riiiid  state  of  the  muscles  caused  by  the  produftK  of  a  former  inllam- 
mutioii  which  have  impaired  the  ela>ticity  and  motion  of  the  muscles. 
The  cases  of  that  kind  that  I  have  seen  have  given  a  history  of  pel- 
vic inflammatii)n— in  two  followinf^  scarlatina,  in  one  from  an  injury 
sustained  by  falling  u})on  the  rail  of  a  fence,  and  in  another  from  a 
perirectal  abscess.  No  difficulty  was  experienced  in  either  case  until 
after  marriage,  when  it  was  found  that  coition  was  impossible.  An  ex- 
amination showed  that  the  vagina  Wcis  rigidly  closed  and  the  nmscles 
of  the  pelvic  floor  could  not  be  distended.  All  efforts  to  move  them 
caused  severe  pain.  In  short,  there  was  muscular  anchylosis.  The 
treatment  for  this  affection  commended  in  the  books  is  to  incise  the 
pelvic  floor  from  the  vaginal  orifice  down  to  the  sphincter-ani  muscle, 
an  operation  entirely  uncalled  for  and  unsatisfactory  in  its  results,  as 
will  be  seen  when  we  discuss  the  treatment. 

Causation. — The  causes  of  these  injuries  are  traumatic  (excepting 
the  last  one  described),  that  is,  overdistention  or  stretching  of  the 
parts  during  parturition.  The  exceptions  to  tiiis  have  already  been 
mentioned,  viz.,  long-continued  overdistention  from  prolapsus  of  the 
]Delvic  organs,  extreme  constipation,  and  malnutrition  in  old  age. 

There  are,  no  doubt,  certain  states  which  j)redis})ose  to  these  in- 
juries. Phlegmatic  women  who  have  failed  to  take  exercise  sufficient 
to  develop  these  muscles  are  liable  to  lacerations  during  parturition. 
In  such  cases  the  muscles  of  the  pelvic  floor  are  poor  in  quality,  and 
rupture  easily  under  extreme  pressure.  The  very  opposite  of  this  ap- 
parently predisposes  to  the  same  accidents.  In  vigorous  muscular 
women  the  pelvic  floor  is  often  unyielding  because  of  the  great 
strength  of  its  muscles.  They  resist  the  pressure  of  the  child  as  it  is 
forced  against  the  pelvic  floor  by  a  powerful  uterus,  and,  seemingly, 
rather  than  relax  and  stretch,  their  union  at  the  median  line  gives 
way ;  it  is  in  such  cases  that  complete  laceration  in  the  first  degree 
is  most  likely  to  occur.  Again,  in  those  in  whom  the  pelvis  is  shal- 
low and  wide  in  the  straits,  the  child  passes  easily  through  the  pelvic 
canal,  when  rather  sudden,  unrestrained  pressure  comes  upon  the 
parts  and  they  are  very  liable  to  give  way.  In  others  still,  either  from 
habits  of  life  or  the  position  of  the  uterus  in  relation  to  the  pelvis, 
the  return  circulation  is  retarded,  the  vessels  become  overdisteuded, 
and  a  deranged  nutrition,  \y\t\\  softening  of  the  tissues  of  the  pelvic 
floor,  renders  them  easily  torn. 

The  immediate  cause  of  lacerations — whcthci-  subcutaneous  or 
complete— is  distention  during  delivery.  The  tissues  in  the  median 
line  give  way  in  the  great  majority  of  cases  because  the  greatest 


INJURIES   TO   THE    PELVIC   FLOOR.  127 

pressure  is  brought  to  bear  at  that  point.  That  the  laceration  ex- 
tends to,  but  not  through,  the  sphincter-ani  muscle,  as  a  rule,  is  no 
doubt  due  to  the  strength  of  this  muscle.  In  fact,  it  is  a  matter  of 
surprise  that  the  sphincter  is  ever  lacerated  when  its  position  is  con- 
sidered in  rehition  to  the  force  brought  to  bear  ujjon  it.  The  only 
rational  explanation  of  the  laceration  which  I  have  been  able  to  ob- 
tain from  a  careful  clinical  study  of  the  matter  is  as  follows :  The 
trausvcrsus-perinfei,  levator-ani,  and  bulbo-cavernosus  muscles  are 
so  strongly  attached  to  the  sphincter-ani  muscles  that,  during  de- 
livery, when  the  head  distends  the  pelvic  floor  they  hold  the  sphinc- 
ter ani  upward  and  forward.  If  the  size  of  the  head  is  out  of  pro- 
portion to  the  distensibility  of  the  pelvic  floor,  one  of  two  injuries 
must  occur :  either  the  muscles  attached  to  the  sphincter  must  give 
way  and  permit  the  sphincter  to  recede  downward  and  escape  injury, 
or  else  the  sphincter  must  be  torn  through.  This  effect  of  the  other 
muscles  upon  the  sphincter  ani  during  delivery  of  the  child's  head 
can  be  seen  by  the  way  in  which  the  sphincter  ani  is  drawn  upward 
until  the  anus  is  distended  an  inch  or  two.  While  the  fetal  head  was 
unusually  distending  the  pelvic  floor,  and  while  the  hand  was  placed 
upon  the  parts  to  "  support  the  perinseum,"  I  have  felt,  or  fancied 
that  I  could  feel,  the  muscles  attached  to  the  sphincter  ani  give  way 
and  permit  the  rectum  to  recede  and  escape  injury. 

Regarding  the  causes  of  injuries  to  the  levator-ani  muscle,  one 
has  but  to  recall  the  phenomena  of  labor  as  related  to  it  to  under- 
stand how  it  may  be  freely  lacerated  in  ordinary  labor.  It  certainly 
is  as  freely  exposed  to  injury  as  some  of  the  other  muscles  which 
we  .know  are  frequently  lacerated  subcutaneously.  In  delivery  with 
forceps,  the  levator-ani  muscle  is  frequently  injured,  I  believe. 
While  the  child's  head  is  in  the  grasp  of  the  forceps  and  during 
traction,  I  have  noticed,  by  passing  the  finger  into  the  rectum,  that 
the  levator  ani  was  drawn  so  tightly  over  the  edges  of  the  blades  of 
the  forceps  that  it  appeared  as  if  it  must  be  torn,  and  I  feel  sure 
that  it  often  is,  I  am  the  more  fully  convinced  of  the  tnith  of  this 
by  having  carefully  watched  patients  that  I  had  delivered  with  for- 
ceps, and  have  found  in  some  of  them  evidence  of  injury  of  the 
levator  ani  above  its  lower  attachment.  That  evidence  was  obtained 
by  finding,  on  subsequent  vaginal  examination,  that  the  resistance 
of  the  levator  muscle  usually  found  was  wanting,  and  also  that  there 
was  prolapsus  of  the  pelvic  floor,  and  loss  of  contractility  upon  irri- 
tating the  parts. 

Treatment. — The  object  in  treating  these  injuries  should  be  to 
restore  the  lacerated  muscles   by  securing  union  of  their  severed 


12S  DISEASES   OF   WOMEN. 

fibers.  In  the  ordinary  or  most  commonly  recognized  injury,  lacera- 
tion in  tliu  median  line  down  to,  but  not  through,  the  Kphincter,  the 
iiinnediate  treatment  usually  employed  is  to  close  the  wound  with 
sutures  at  once,  or  to  cleanse  the  wound  from  blood-clots  and  coapt 
the  parts,  carefully  bind  the  patient's  limbs  together,  and  trust  that 
union  may  follow.  The  treatment  by  the  innnediate  use  of  the 
suture  will  be  made  plain  by  the  following : 

Pi'imanj  Operation. — The  wound,  if  seen  wlien  it  occurs,  is  tri- 
angular, the  base  running  parallel  to  the  rectum  and  the  apex  being 
at  the  posterior  part  of  the  vulva.  The  sides  of  the  wound  come  to- 
gether quite  easily,  and  only  require  well-adjusted  sutures  to  keep 
them  in  position.  IMuch  care  is  necessary  in  using  the  sutures.  If 
they  are  imperfectly  introduced  they  do  harm  by  preventing  the  union 
which  often  takes  place  without  surgical  aid.  If  one  is  not  accus- 
tomed to  this  simple  operation  of  closing  the  wound  with  sutures,  it 
would  be  infinitely  better  for  the  patient  to  trust  to  nature  than  to 
have  the  surgeon  employ  sutures  in  a  bungling  way.  The  sutures 
should  be  introduced  as  follows:  The  needle,  held  in  the  groove  at 
right  angles  to  the  forceps,  should  be  entered  in  the  skin  exactly  at 
the  edge  of  the  wound,  and  as  far  down  as  the  deepest  part ;  it  is  then 
carried  into  the  tissues  and  made  to  describe  the  arc  of  a  circle  and 
emerge  at  tlie  margin  of  the  mucous  membrane  of  the  vagina.  The 
needle  is  again  introduced  on  the  opposite  side  and  carried  through  as 
before,  and  brouglit  out  at  the  point  in  the  skin  opposite  where  it  was 
first  introduced.  If  this  is  properly  done,  the  position  of  the  suture  in 
the  tissue  will  be  as  represented  in  Fig.  67.  The  center  lines  repre- 
sent the  sides  of  the  wound  and  the  dotted 
THemI)r^np-  ^^^®  shows  the  suture,  which  describes  a 
circle,  the  point  at  which  the  suture  is 
I  tied  and  the  opposite   point  of  its  cir- 

'  skin  cumference  being  at  the  ujiper  and  lower 
angles  of  the  wound.  There  are  three 
advantages  in  using  the  suture  in  this 
way  :  First,  the  ends  of  the  suture  com- 

FiG.  eV.-Diagratn  of  the  sweep  of    -        ^^^^   ^^  ^^^^   ^^         ^f  ^^^^  ^^o\m^  hold 
the  suture.  ^  '^ 

the  parts  exactly  together  without  the 

aid  of  superficial  sutures ;  second,  the  cui-ve  which  the  suture  takes 
deep  under  the  tissues  brings  the  central  ]>ortions  of  the  wound  to- 
gether, whereas,  if  the  suture  is  passed  straight  tlu'ough  the  tissues, 
the  edges  of  tlie  wound  would  curve  inward,  while  the  central  parts 
would  not  meet.  Fig.  08  shows  the  ])arts  adjusted  by  a  proper  su- 
ture, while  Fig.  69  show^s  the  effect  of  the  imperfect  one.     Again, 


INJURIES  TO   THE  PELVIC  FLOOR.  129 

the  suture  running  deep  into  tlie  tissues  gives  additional  surety  of 
catching  the  ends  of  the  muscles  so  as  to  reunite  them,  which  is  the 
chief  object  of  tlie  operation.  In  the  pri- 
mary operation — i.  e.,  the  introduction  of  su- 
tures immediately  after  the  injury  occurs — 
Peaslee's  needle  is  easier  to  use  than  the  or- 
dinary perineal  needle.  Fig.  TO  shows  the 
instrument.  This  needle,  with  a  handle,  and 
an  eye  near  the  point,  is  armed  with  a  thread   fi«s- «?-  69.— Sutures  proper- 

•^  1T11  •  ttV  i"'^  improperly  mtroauced. 

and  passed  through   the   tissues  as  already 

ilescribed,  and  the  end  of  the  suture  is  passed  under  the  thread  in 
the  needle ;  this  is  then  witlidrawn  and  brings  one  end  of  the  suture 
into  the  tissues.     The  operation  is  repeated  on  the  other  side,  wliich 


~n^ 


Fig.  70. — Peaslee's  needle. 

completes  the  introduction  of  the  suture.  The  only  advantage  of 
this  needle  is  that  it  is  easier  to  manage  than  the  ordinary  one 
It  can  only  be  used,  however,  in  the  primary  operation.  The  silk 
suture  properly  prepared  is  by  far  the  best  for  the  immediate  opera- 
tion. Silver  wire,  which  at  one  time  was  the  only  suture  which 
could  be  relied  upon,  has  been  superseded  by  others  that  are  vastly 
superior  for  this  purpose.  It  is  impossible  to  keep  the  parts  clean 
after  confinement  without  causing  pain  while  the  ends  of  silver-wire 
sutures  are  projecting  from  the  parts.  The  silk  sutures  save  the 
patient  much  discomfort,  and  are  not  in  the  way  of  the  means  neces- 
sary to  be  used  to  keep  the  parts  clean. 

This  constitutes  the  whole  primary  treatment  of  injuries  of  the 
pelvic  floor,  as  given  in  our  text-books — a  kind  of  management  gen- 
erally sufficient  in  central  lacerations,  but  that  can  have  little  influ- 
ence in  restoring  the  other  forms  of  injury.  To  secure  the  reunion 
of  the  muscles  that  have  been  lacerated  subcutaneously,  especially 
the  levator  ani,  the  parts  should  be  well  supported  and  kept  at  rest. 
If  the  pelvic  floor  is  permitted  to  remain  in  its  relaxed  and  displaced 
position  there  is  but  little  chance  of  the  lacei-ated  muscles  uniting, 
nor,  in  case  they  are  simply  overtaxed  by  distention,  will  they  regain 
their  tonicity  promptly  if  left  unaided  by  support.  Especially  is 
restoration  likely  to  be  prevented  if  the  patient  is  permitted  to  as- 
sume the  erect  position  too  soon,  and  if,  to  increase  the  injurious 
effects  of  this  unwise  liberty,  the  uterus  is  crowded  down  into  the 
10 


130  DISEASES   OF    WOMEN. 

pelvis  by  a  compress  and  ti<z;lit  bandage  applied  around  tlie  body. 
In  all  eases  of  injury  in  Avliieh  eonectdcd  laceration  of  tlic  innseles  is 
suspected,  the  jK-lvic  floor  should  be  well  su])])ortc'd  with  a  coni]>res6 
and  bandage  fastened  to  the  aljdoniinal  binder.  V>y  these  means  the 
severed  ends  of  the  muscular  fibers  are  brought  nearer  together,  so 
that  they  have  a  better  chance  to  unite.  An  objection  would  natu- 
rally be  raised  to  this  treatment  on  the  ground  that  it  would  obstruct 
the  free  flow  of  the  lochia.  This  can  be  overcome  bv  makiiiir  the 
compress  of  absorbent  cotton,  antiseptic  gauze,  or  marine  lint,  and 
draining  the  vagina  with  a  drainage-tube  or  a  strip  of  gauze  oi-  lint. 
I  believe  that  in  this  way  the  vagina  can  be  drained  and  kei)t  as 
clean  as  it  can  be  by  occasional  douching.  In  fact,  I  am  inclined  to 
think  that  the  very  frequent  use  of  vaginal  injections  so  generally 
employed  in  this  age  of  antisei:)tic  obstetrical  practice  often  tends  to 
retard  the  restoration  of  injuries  of  the  pelvic  floor.  It  is  well,  also, 
to  let  the  patient  rest  upon  either  side  after  the  first  twelve  or 
twenty-four  hours.  This  position  takes  off  all  pressure  from  above, 
and  favors  the  upward  inclination  of  the  pelvic  floor.  Great  care 
should  be  taken  to  avoid  distention  of  the  bladder  and  rectum.  Con- 
stipation after  coniinement  is  almost  sure  to  prevent  or,  at  least, 
retard  recovery.  By  attending  to  these  simple  means  nmch  can  be 
done  toward  preventing  that  incurable  condition,  permanent  paraly- 
sis from  atrophy. 

After  convalescence  from  confinement,  in  case  it  is  found  that, 
although  there  is  no  complete  loss  of  muscular  action  in  any  ])art  of 
the  pelvic  floor,  there  is  a  muscular  weakness  shown  by  the  inijiaired 
power  of  resistance  to  pressure,  the  supporting  treatment,  with  judi- 
cious rest  and  exercise  well  regulated,  should  be  kept  uj)  until 
strength  is  restored. 

The  restoration  of  the  function  of  the  muscles,  as  already  stated 
in  speaking  of  general  treatment,  is  the  great  object  of  all  surgical 
operations  for  the  relief  of  these  injuries  of  the  pelvic  floor.  It 
matters  not  how  much  tissue  may  be  gathered  together  and  united 
in  the  region  of  the  perineal  body,  it  will  have  no  functional  action 
if  destitute  of  muscular  tissue.  The  success  of  all  surgical  ]u-oced- 
ures  depends  upon  the  restoration  of  the  muscles,  elastic  tissue,  and 
fascia,  and  not  the  mere  uniting  of  the  tegumentary  and  areolar 
tissue. 

In  this  plastic  operation,  known  as  pcrincorrhaph}',  or  I'cstoration 
of  the  perinaeum,  much  surgical  skill  is  necessary  in  order  to  succeed. 
This  is  true  of  all  operative  surgery,  and  yet  special  care  is  necessary 
in  this  operation,  because  union  by  first  intention  must  be  secured 


INJURIES   TO   THE   PELVIC  FLOOR.  131 

or  else  the  operation  will  fail.  In  many  operations  in  surgery,  if 
the  wound  does  not  heal  by  first  intention,  union  may  be  secured  l>y 
granulation  and  a  perfect  result  obtained ;  but  in  the  operation 
under  consideration,  if  the  whole  or  any  part  fails  to  unite  promptly, 
partial  or  complete  failure  is  the  result.  This  calls  for  the  employ- 
ment of  all  known  surgical  means  most  favorable  to  prompt  healing. 
On  this  account,  then,  some  general  considerations  regarding  plastic 
operations  in  gynecology  will  be  in  place  before  describing  the 
methods  of  operating.  What  will  follow  on  this  subject  will  apply 
equally  to  all  operations  about  the  pelvic  floor  and  pelvic  organs, 
especially  lacerations  of  the  cervix  uteri. 

The  following  may  be  given  as  the  conditions  necessary  for  the 
healing  of  the  wounds  in  question  : 

1.  A  condition  of  the  wound  and  of  the  general  system  favorable 
to  the  repair  of  injuries. 

2.  Perfect  coaptation  and  retention  of  the  parts  to  be  united,  and 
protection  of  the  parts  from  extrinsic  and  offending  agents  during 
and  after  coaptation. 

If  these  conditions  are  all  secured,  success  must  of  necessity  fol- 
low. The  management  of  wounds  is  not  a  matter  of  blind  chance. 
The  process  of  repair  in  living  tissues  is  governed  by  definite  laws 
which  are  always  the  same  under  identical  circumstances.  To  ob- 
tain the  conditions  necessary  to  the  fulfillment  of  these  laws  is  often 
difiicult  and  sometimes  impossible;  still,  the  nearer  we  come  to  all 
the  requirements  the  more  surely  will  the  desired  ends  be  accom- 
plished. 

The  first  of  these  conditions,  viz.,  good  general  health,  may  be 
found  wanting  in  many  ways  and  degrees  which  are  too  familiar  to 
require  notice,  but  there  are  some  of  these  which  may  be  mentioned 
because  they  are  very  often  overlooked — preoccupation  of  the  sys- 
tem by  some  highly  taxing  function,  like  lactation,  for  example,  and 
certain  deranged  states  of  the  nervous  system.  These  certainly  have 
an  important  bearing  upon  the  healing  of  wounds,  although  little  if 
anything  is  said  in  our  works  on  surgery  regarding  them.  In  fact, 
there  is  good  reason  for  believing  that  enfeebled  states  of  the  nerv- 
ous system  have  much  to  do  with  retarding  the  healing  of  wounds, 
even  when  the  general  nutrition  appears  to  be  normal.  We  fre- 
quently hear  surgeons  say  that  patients  recover  from  injuries  much 
more  promptly  when  they  have  courage  and  hope  without  fear;  but 
exhausted  and  irritable  states  of  the  nervous  system  retard  the  pro- 
cess of  repair,  although  the  patient  may  be  indifferent  or  perfectly 
satisfied  in  regard  to  recovery. 


132  DISEASES  OK   WOMEN. 

Regarding  the  imfavorable  conditions  of  tlie  tissues  generally 
met  with,  the  following  are  the  most  ini])ortant : 

Contusions. — Contusions  accompanying  wounds  caused  by  par- 
turition..  Lacerated  wounds  of  the  pelvic  organs  often  heal  promptly  I 
if  well  coaptated  immediately  after  they  occur,  but  no  such  union 
should  be  expected  in  case  the  tissues  are  greatly  contused.  AVhile 
this  is  true  of  the  immediate  treatment  of  wounds  sustained  during 
laboi',  it  is  pretty  definitely  settled  that  operation  wounds  made  dur- 
ing the  process  of  involution — that  is,  within  four  or  six  weeks  after 
continement — often  fail  to  unite.  From  this  we  learn  that  while 
tissues  are  undergoing  involution  they  are  not  in  the  best  condition 
to  heal ;  and  also  that,  when  involution  is  delayed  beyond  the  usual 
time,  treatment  should  be  employed  to  complete  the  process  before 
undertaking  plastic  operations. 

Scrupulous  care  is  also  required  in  preparing  the  tissues  by  mak- 
ing clean,  accurate  incisions  which  will  give  smooth  surfaces  to  the 
parts  to  be  united.  Old  scar  tissue  should  also  be  removed  from  all 
wounds  where  union  by  first  intention  is  desired.  These  are  rules 
in  surgery  which  are  well  known,  but  they  are  sometimes  overlooked 
in  practice. 

HcmiorrTiage. — Haemorrhage  in  tliese  operations  is  often  a  source 
of  diflSculty  and  delay  to  the  operator,  but,  worse  than  that,  it  is 
sometimes  the  cause  of  failure.  In  the  vast  majority  of  s^urgicai 
operations  all  that  is  required  of  the  surgeon  is  to  arrest  the  hremor- 
rhage,  by  any  of  the  ordinary  means,  in  order  to  secure  a  good  re- 
sult ;  but  in  the  operations  in  question,  if  some  kinds  of  styptics 
are  used,  they  prevent  union.  Cases  differ  so  very  much  in  regard 
to  haemorrhage  that  I  have  given  much  thought  to  the  predisposing 
causes  of  this  bleeding  tendency,  so  marked  in  some  patients.  The 
hfemorrhagie  diathesis  in  its  most  typical  form  is  generally  found 
in  men,  but  a  less  marked  haemorrhagic  tendency  is  common  to 
many  women,  and  these  are  very  unpleasant  subjects  to  operate 
upon.  During  the  past  few  years  it  has  been  my  misfortune  to 
meet  with  quite  a  number  of  cases  in  which  the  bleeding  tendency 
was  noticeable.  The  cause  of  this  in  most  of  them,  I  think,  was  im- 
paired general  health,  due  to  exhausting  conditions  of  life  rather 
than  to  any  congenital  imperfection  of  the  blood  itself.  Another 
very  important  element  I  have  found  to  be  mechanical  intei-ruptioi 
of  the  circulation,  the  pelvic  organs  becoming  congested  from  re 
tardation  of  the  portal  circulation,  induced  by  hepatic  disordei 
sedentary  habits,  tight  lacing,  and  so  forth.  The  products  of  formei 
pelvic  inflammations,  such  as  pelvic  cellulitis,  also  tend  to  maintain! 


INJURIES  TO   THE   PELVIC  FLOOR.  133 

a  hypersemic  state  of  tlie  pelvic  organs  ;  this  we  often  find  long  after 
all  evidence  of  active  iiiHaunnation  lias  subsided.  The  condition  at 
the  time  also  is  often  favorable  for  bleeding ;  the  well-defined  vas- 
cularity which  exists  in  conditions  such  as  imperfect  involution  in- 
sures hirmorrhage  in  all  operations  undertaken  during  such  unfavor- 
able states.  The  possible  haemorrhage  from  such  causes  can  be 
avoided  by  the  proper  selection  and  preparation  of  cases  before  oper- 
ating. 

The  rule  which  should  be  followed  in  this  matter  is  to  secure  the 
best  possible  state  of  the  general  health  of  the  patient,  and  to  reduce 
all  hyperremic  states  of  the  pelvic  organs  as  far  as  possible.  This  is 
generally  possible  to  a  great  extent,  because  the  object  of  plastic 
operations  is  to  restore  the  organs  to  their  original  form  and  stract- 
ure,  differing  in  this  regard  from  many  other  operations  in  surgery 
which  have  for  their  object  the  removal  of  diseased  parts. 

In  carrying  oat  this  plan  of  treatment,  however,  there  is  one 
difficulty  encountered  in  practice ;  when  patients  are  ill  and  suffer- 
ing they  will  gladly  accept  any  operation  which  promises  them  relief, 
but,  when  they  are  free  from  pain  and  have  gained  in  health,  they 
hesitate  about  undergoing  any  surgical  treatment  which  is  designed 
to  keep  them  from  suffering  in  the  future.  This,  however,  does  not 
prevent  the  surgeon  from  advising  that  which  is  best.  There  are 
patients — fortunately  very  few — who  have  the  hsemorrhagic  diathesis 
sufficiently  marked  to  debar  them  from  operations,  and  it  is  doubtful 
if  any  preparatory  treatment  will  change  this  constitutional  pecul- 
iarit3^  Such  subjects  should  be  let  alone ;  to  operate  in  these  cases 
is  dangerous,  and  almost  always  ends  in  failure.  I  have  had  three 
such  cases  in  the  past  five  years;  two  of  them  were  operated  upon 
before  discovering  their  peculiarity,  the  result  being  depletion  of 
the  patients  without  any  benefit  from  the  operation,  and  the  devel- 
opment of  extreme  caution  on  the  part  of  the  operator  in  selecting 
cases  in  future.  The  third  case  was  diagnosticated  earlier,  and  I 
declined  to  operate. 

The  management  of  bleeding  vessels  in  these  operation  wounds 
is  of  great  importance.  All  haemorrhage  should  be  arrested  before 
bringing  the  parts  together,  because  a  slight  oozing,  which  would  do 
no  harm  in  a  wound  to  be  treated  by  open  dressing,  may  jDrevent 
union  in  wounds  in  which  drainage  should  not  be  employed,  or,  at 
least,  should  not  necessarily  be  required.  This  often  requires  an 
amount  of  time  which  the  surgeon  reluctantly  bestows,  but  success 
in  treating  this  class  of  wounds  depends  largely  upon  attention  to 
this  matter.    Still  more,  the  means  used  to  arrest  hiemorrhage  should 


134  DISEASES   OF    WOMEN. 

be  sncb  tis  will  not  interfere  with  the  process  of  healing.  Hitherto 
the  means  ein])l()VLd  have  been  ligation  or  torsion  of  the  large  vessels, 
and  for  minor  bleeding  the  use  of  ice  or  cold  water.  More  recent 
experience  lias  pointed  out  objections  to  these  means.  Chilling  the 
tissues  by  cold  is  injurious,  it  is  said,  and  no  doulit  the  statement  is 
true.  It  has,  fortunately,  been  found  that  hot  water  is  more  efficient 
in  controlling  hsemorrhage,  and  its  effects  upon  the  tissues  are  not 
unfavorable — hence  its  use  as  a  styj)tic  in  these  operation  wounds  is 
strongly  commended.  Torsion  is  objectionable,  because  it  is  less 
certain  to  control  bleeding  than  the  hgature,  and  quite  as  liable  to 
give  rise  to  suppuration.  In  view  of  this  fact,  it  may  be  said  without 
doubt  that  the  antiseptic  ligature  is  the  best  means  of  controlling  the 
vessels  in  these  wounds.  Regarding  the  material  to  be  used  as  a 
ligature,  it  may  be  said  that  that  which  can  be  inclosed  in  the  wound 
without  giving  subsequent  trouble  is  the  thing  required.  The  prop- 
erly-prepared catgut  ligature  fulfills  the  indications.  Some  recent 
experience  indicates  that  the  Japanese  ligature,  made  of  whale-sinew, 
is  the  best,  owing  to  its  being  absorbed  with  gi-eat  facility.  Occa- 
sionally, in  deep  lacerations,  a  small  artery  on  each  side  may  require 
to  be  ligated ;  the  chief  arterial  bleeding,  however,  comes  from  the 
upper  portion,  the  small  vessels  coming  apparently  from  above  down- 
ward in  the  areolar  tissue,  between  the  rectum  and  vagina.  These 
sometimes  bleed  quite  freely,  and  they  are  not  controlled  by  tighten- 
ing the  sutures,  which  arrest  the  haemorrhage  at  points  lower  down. 
Such  vessels  I  control  by  passing  a  needle  through  the  vaginal  mu- 
cous membrane  above  the  denuded  surfaces,  and  thus  carry  a  ligature 
under  the  bleeding  vessels,  tying  it  over  the  free  surface,  chec;kiug 
the  bleeding  on  the  principle  of  acupressure.  The  sutures  can  b^. 
left  in  position  until  tlie  perinreum  has  completely  healed  ;  they  can 
then  be  removed  with  the  aid  of  the  speculum.  Occasionally  it  be- 
comes necessary  to  ligate  some  of  these  vessels  which  bleed  persist- 
ently and  can  not  be  controlled  in  the  way  I  have  previously  de- 
scribed ;  it  is  then  well  to  ligate  them  with  a  line  catgut  ligature,  the 
ends  being  cut  off  short  and  inclosed  in  the  wound. 

In  spite,  however,  of  all  precautions,  secondary  luiMnorrhage  will 
occasionally  occur  after  this  operation.  I  have  met  with  four  such 
cases  in  my  j^ractice ;  in  one  of  them  it  occurred  on  the  seventh 
day  after  the  operation.  In  all  of  them  the  bleeding  took  place  from 
the  upper  or  vaginal  portion  of  the  wound,  the  blood  flowing  into 
and  widely  di-stending  the  vagina  before  appearing  externally. 

In  my  first  case  I  was  obliged  to  remove  the  sutures,  empty  the 
vagina  of  blood-clots,  and  ligate  the  bleeding  vessels.     This  resulted 


INJURIES  TO  THE   PELVIC   FLOOR.  135 

fii  spoiling  my  operation,  for,  although  I  reintroduced  tlie  sutures, 
union  did  not  take  place.  This  haemorrhage  occurred  on  the  sec- 
ond day. 

In  my  three  subsequent  eases  I  secured  much  better  results.  In- 
troducing a  Sinjs's  specuhnn  on  the  (interior  side  of  the  vagina,  I 
removed  the  clots  and  blood  by  sponging,  and  then,  throwing  light 
into  the  vagina  by  means  of  a  concave  reflector,  I  was  able  to  see 
that  the  blood  welled  up  from  the  upper  portion  of  the  wound.  In 
place  of  i)ulling  the  edges  of  the  wound  apart  and  searching  for  the 
bleeding  vessels,  I  passed  a  curved  needle  and  ligature  down  and 
around  the  ])lace  where  the  bleeding  came  from,  and  was  al)le,  by 
tightening  \nj  ligature  moderately,  to  control  the  bleeding  entirely. 
These  cases  subsequently  did  well,  and  the  result  of  the  operation 
was  good. 

Sutu/vs. — The  coaptation  of  the  tissues  by  means  of  sutures  re- 
quires more  than  a  passing  notice. 

The  success  which  J.  Marion-Sims  obtained  with  the  silver-wire 
suture  led  at  once  to  its  general  use  in  gynecological  operations. 
There  is,  however,  good  reason  for  believing  that  the  results  obtained 
by  that  great  surgeon  depended  as  much  upon  his  skill  in  using  sut- 
ures as  upon  the  material  which  he  used. 

To-day  we  know  that  it  matters  little  whether  silver-wire  or  pre- 
pared silk  sutures  are  used,  provided  they  are  properly  introduced. 
The  silk  selected  should  be  braided,  and  not  the  twisted  variety,  for 
the  reason  that  the  braided  silk  retains  wax  much  better,  and  does 
not  unravel  on  being  handled.  The  wax  in  the  twisted  silk  breaks 
and  separates  from  the  silk,  and  the  silk  thereby  becomes  porous 
and  will  absorb  blood-serum  which  readily  decomposes.  The  reason 
why  surgeons  formerly  failed  in  the  operation  for  vesico-vaginal 
flstula,  when  they  used  silk,  was  because  the  organic  matter,  ab- 
sorbed by  the  unprepared  silk,  decomposed  and  caused  septic  inflam- 
mation. The  braided  silk,  properly  saturated  with  wax,  overcomes 
this  completely.  The  parts  to  be  united  should  be  brought  together 
and  held  there  without  any  straining  upon  the  sutures.  It  is  equally 
important  to  introduce  the  sutures  so  that  they  will  prevent  the  in- 
curving of  the  undenuded  edges  of  the  parts  to  be  united,  and, 
finally,  a  sufficient  number  of  sutures  should  be  employed  to  secure 
uniform  retaining  pressure  at  all  parts  of  the  wound. 

These  are  facts  which  every  one  is  supposed  to  know  before  en- 
gaging in  surgery,  but  in  practice  a  large  number  of  failures  are  seen 
because  of  neglect  in  regard  to  them. 

The  management  of  these  wounds  during  the  healing  process 


13G  DISEASES   ur   WUMLN. 

dilfers  somewhat  from  the  modern  treatment  of  womids  in  gen- 
eral. 

Dressings. — The  antiseptic  dressings  which  surgeons  use  in  some 
form  or  other  are  difficult  of  application  in  the  ojjerations  for  restor- 
ing the  cervix  uteri  and  perina*um.  So  fully  is  this  the  case  that 
some  of  our  highest  authorities  on  gynecology  make  no  pretensions 
to  using  antiseptic  treatment  in  such  wounds,  unless  frequent  bath- 
ing of  the  parts  with  water  and  carbolic  acid  may  be  called  such. 
No  doubt  some  of  our  best  operators  get  good  results  with  this  kind 
of  after-treatment,  but  it  is  more  than  probable  that  still  better  re- 
sults can  be  obtained  by  treatment  more  in  accordance  witli  the  rules 
of  antiseptic  surgery.  Viewed  in  the  light  of  modern  investigation, 
it  appears  that  the  frequent  douching  of  wounds  with  carbolized 
water  is  a  practice  at  least  ten  years  behind  the  surgery  of  to-day. 

In  treating  wounds  of  the  perina;nm  there  are  many  perplexing 
difficulties  in  the  way  of  obtaining  a  proper  antiseptic  dressing. 
Here,  also,  the  vaginal  douche  has  been  freely  used,  for  the  purpose, 
it  is  said,  of  remo^dng  vaginal  secretions  which  might  irritate  the 
wound  and  prevent  its  healing.  Such  treatment  is  generally  un- 
necessary, if  not  injurious.  In  all  operations  for  repairing  old  injuries 
of  the  perinteum  it  is  better  to  first  cure  all  uterine  and  vaginal  dis- 
eases which  give  rise  to  abnormal  discharges.  That  is  the  only  sure 
way  of  protecting  the  operation  wound  from  that  soui'ce  of  disturb- 
ance. This,  of  course,  can  not  be  accomplished  in  the  treatment  of 
lacerations  immediately  after  confinement.  Then  it  becomes  a  very- 
important  question  how  to  protect  the  perineal  wound  from  the 
lochia.  Various  means  have  been  suggested  for  this  pui-j)Ose,  such 
as  coating  the  vaginal  surface  of  the  wound  with  collodion,  placing 
carbolized  lint  or  borated  cotton  upon  the  inner  portion  of  the  wound, 
and,  the  most  common  of  all,  the  frequent  use  of  vaginal  injections. 
It  is  hardly  possible  to  say,  at  the  present  time,  which  is  best.  The 
collodion  has  not  l)een  tried  often  enough  to  speak  positively  rcganl- 
ing  it.  In  using  the  lint  or  cotton  tliere  is  danger  of  separating  the 
edges  of  the  wound,  the  very  thing  of  all  others  to  be  avoided. 
Perhaps  the  best  treatment,  after  carefully  cleansing  the  parts  and 
bringing  them  accurately  together,  is  to  let  the  wound  alone  for  about 
two  days,  trusting  that  during  this  time  it  may  become  sufficiently 
protected,  by  a  coating  of  fresh  lymph,  to  resist  the  subsequent  dis- 
charges. After  the  lochia  l)egin  to  decompose,  the  frequent  use  oi 
the  vaginal  douche  is  advisable,  and  should  be  continued  until  the 
union  is  completed. 

In  the  secondary  operation  for  restonug  the  perinteum,  the  vag- 


INJUEIES   TO   THE   PELVIC   FLOOR.  137 

iiijil  j)()rtion  of  the  wound  may  generally  be  left  alone.  It  is  pro- 
tected from  the  air  l)y  the  anterior  vaginal  wall,  which  makes  a  suit- 
able dressing  provided  the  uterus  and  vagina  are  in  a  normal  condition, 
as  thev  should  be,  before  the  operation  is  done.  If  suppuration  takes 
i)lace  and  ])iis  is  discharged  into  the  vagina,  it  should  be  disposed  of 
l)v  injections.  The  outer  portion  of  the  wound  may  also  be  left 
without  dressing,  but  it  is  better  to  apply  lint  or  cotton  upon  each 
side  of  the  sutures ;  if  silver  wire  is  used,  or  if  silk  is  employed,  the 
lint  can  be  placed  over  the  wound  and  retained  in  place  by  keeping 
the  limbs  together.  The  advantage  of  this  kind  of  dressing  is  that 
it  absorbs  any  discharge  that  there  may  be. 

Perhaps  the  most  important  point  of  all  in  the  management  of 
such  cases  is  to  keep  from  dropping  urine  upon  the  wound.  The  most 
scrupulous  care  should  be  taken  to  close  the  end  of  the  catheter  in 
withdrawing  it.  If  this  is  neglected,  a  few  di'ops  of  urine  will  escape 
from  the  eye  of  the  instrument,  and,  falling  upon  the  wound,  will 
cause  trouble.  The  nurse  should  be  carefully  instructed  to  use  the 
catheter  in  this  way,  and,  to  make  doubly  sure  of  cleanliness,  a  little 
absor])eut  cotton  should  be  placed  between  the  meatus  urinarius  and 
the  wound  every  time  the  instrument  is  used. 

Notwithstanding  all  this  care,  suppuration  "will  sometimes  occur, 
and  then  the  question  arises  how  to  manage  this  complication.  If 
the  suppuration  is  limited  to  the  track  of  one  suture,  that  one  may 
be  removed  and  the  remaining  ones  tnisted  to  keep  the  parts  to- 
gether. It  sometimes  happens  that  a  cellulitis  which  begins  in  the 
region  of  the  sutures  extends  outward  and  ends  in  suppuration. 
This  should  be  treated  by  a  free  incision  and  drainage,  which  may 
save  the  operation.  On  the  other  hand,  if  suppuration  takes  place 
between  tlie  surfaces  to  be  united,  there  is  very  little  hope  of  obtain- 
ing union  at  all  by  any  kind  of  treatment.  A  partial  or  even  com- 
])]ete  success  may  be  obtained  in  such  cases  if  the  suppurative  process 
is  detected  early,  and  drainage  from  the  lower  edge  of  the  wound  is 
established.  This  can  be  effected  by  loosening  one  or  more  of  the 
sutures,  and  then  introducing  carbolized  silk  thread  or  catgut  to 
secure  the  free  escape  of  the  inflammatory  products. 


DESCRIPTION   OF   THE   OPERATION   FOR   RUPTURE   IN   THE 
FIRST   DEGREE. 

Yelpeau,  of  Paris,  was  the  surgeon  who  first  operated  for  the 
restoration  of  the  pcriuieum. 

The  first  part  of  the  operation  consists  in  denuding  the  surfaces 


138 


DISEASES   OF    WOMEN. 


tf>  be  united.  The  extent  to  which  this  should  he  carried  depends 
U])<»n  the  character  of  the  injury.  If  tliere  is  no  i)r()la])sus  of  the 
pelvic  tioor  or  of  the  posterior  vaginal  wall  (see  Fig.  <W»jj  it  will  suttice 
to  denude  the  surfax^es  as  far  as  the  original  laceration  extended  and 
no  farther.  This  can  be  done  by  tracing  the  outline  of  the  scar  tis- 
sue formed  by  the  healing  after  the  laceration.  This  scar  tissue  con- 
tracts and  brings  the  normal  tissues  toward  each  other  so  that  the 
portion  to  be  exsected,  as  indicated  by  the  rule  given  here,  appears 
to  be  very  small  and  insufhcieut ;  but,  when  the  scar  tissue  is  re- 
moved, the  skin  and  mucous  membrane  retract  and  make  the  denuded 
surface  large  enough — much  larger,  in  fact,  than  the  piece  of  tissue 
taken  away.  If  more  tissue  is  removed  in  such  cases  and  good  union 
is  obtained,  the  introitus  vaginaB  is  made  too  small. 

When  the  sides  of  the  laceration  ai-e  drawn  outward  and  the  pel- 
vic floor  is  prolapsed,  and  the  distance  from  t]ie  meatus  urinarius  to 
the  anterior  portion  of  the  sphincter  ani  is  increased  to  an  abnormal 
degree  (see  Fig.  66),  the  denudation  should  be  made  high  enough  on 
eitlier  side  to  make  sure,  if  possible,  to  unite  the  loose  ends  of  the 
l)ulbo-cavemosus  muscle.  To  do  this  the  original  scar  tissue  should 
not  be  taken  as  a  guide  in  vivifying  the  parts.  On  tlie  contrary,  the 
vivifying  should  be  carried  upward  on  either  side  to  within  an  inch 
or  less  of  the  lower  side  of  the  vestibule.  In  this  condition  there  is 
usually  prolapsus  of  the  posterior  vaginal  wall,  and  when  such  is 
the  case,  the  denudation  should  be  carried  upward  nearly  to  the  high- 
est point  on  the  prolapsed  portion  of  the  vaginal  wall.     (See  Fig.  67.) 

The  instruments  for  denuding  the  parts  are  a  number  of  s])onges 
fixed  in  holders,  a  tissue  forceps  (see  Fig.  71),  and  Emmet's  curved 


Fig.  71. — Tissue  forceps. 

scissors,  four  in  number,  two  with  lesser  curves  and  two  with  greater. 
(See  Figs.  72  and  73.)  These  instruments  can  not  be  described; 
they  must  be  seen  to  be  understood. 


Emmet's  curved  scissors. 


INJURIES  TO  THE   PELVIC   FLOOR. 


139 


Tlie  method  of  operating  is  as  follows :  The  patient  is  placed 
upon  the  operating-table  in  the  lithotomy  position ;  an  assistant  on 


each  side  holds  the  limb  of  that  side  in  the  flexed  position  with  one 
hand,  while  with  the  other  he  separates  the  labia  to  fully  expose  the 
parts ;  the  operator,  seated  in  front  of  the  patient,  seizes  the  tissues 
with  the  forceps  on 
the  left  side  as 
high  up  as  the  den- 
udation should  ex- 
tend, and  with  the 
scissors  removes  a 
strip  at  the  junc- 
tion of  the  skin  and 
mucous  membrane 
across  to  a  corre- 
sponding point  on 
the  right.  The  end 
of  the  strip  should 
be  left  attached, 
the  other  scissors 
taken,  and  the  strip 
continued  back  to 
the  left  again.  In 
this  way  the  con- 
tinuous sti'ip  may 
be  taken  out  from 
one  side  to  the 
other  and  back 
again  until  the 
whole  surface  is  de- 
mided.  The  three 
ligures  wuU  give  a  better  idea  of  the  mode  of  procedure  than  this  de- 
scription. 

In  case  there  is  prolapsus  of  the  vagina,  and  it  is  therefore  neces- 


FiG.  74. — First  step;  denudation  begun. 


uo 


DISEASES   OF   WOMEN. 


strip 


sary  to  carry  the  denudation  liio:li  up  on  tlie  vaginal  wall,  the  scissors 
with  the  greatest  curve  should  be  used  at  that  part  of  the  jirocedure. 

When  the  whole  surface 
has  been  denuded  in  the  man- 
ner described,  it  is  necessary 
to  make  sure  that  the  edges 
of  the  wound  are  straight  and 
alike  on  both  sides,  and  that 
the  surface  is  smooth.  This 
can  be  accomplished  by  caus- 
ing the  assistants  to  put  the 
parts  upon  the  stretch,  Avhen 
careful  sponging  will  show 
any  irregularity  which  needs 
to  be  trimmed  oft".  By  pass- 
ing the  finger  over  the  fresh 
surface,  any  scar  tissue  that 
remains  can  be  detected  by 
its  density  and  resistance  com- 
pared with  the  softness  and 
elasticity  of  the  normal  tissue. 
At  this  stage  of  the  opera- 
tion attention  should  be  given 
to  ha?morrhage.  If  there  are 
any  spurting  vessels  in  the 
wound  they  should  be  con- 
trolled by  suture  or  ligature.  Fortunately,  when  such  vessels  are 
encountered  they  are  generally  at  the  upper  margin  of  the  wound 
and  may  be  controlled  by  passing  a  fine  suture  through  the  mucous 
membrane  of  the  vagina  and  under  the  vessel  and  then  tying  it  tight 
enough  to  stop  the  bleeding.  This  has  been  ah-eady  noticed  under 
the  head  of  general  observations. 

Kext  in  order  comes  the  introduction  of  the  sutures,  and  just 
here  it  may  be  stated  that  for  all  plastic  operations  I  use  silk  sutures 
prepared  as  follows :  The  ordinary  braided  silk  is  immersed  five  or 
six  hours  in  wax  containing  six  per  cent  of  carbolic  acid  and  six  per 
cent  of  salicylic  acid.  The  wax  is  kept  all  the  time  at  a  tempera- 
ture high  enough  to  liquefy  it.  This  long  immersion  in  the  melted 
wax  is  necessary  to  thoroughly  saturate  the  silk,  "When  this  is  ac- 
comphshed,  the  silk  is  drawn  through  a  carbolized  sponge  to  remove 
any  excess  of  the  wax.  It  is  then  put  on  a  reel  which  is  placed  in  a 
close-stoppered  bottle  and  ke])t  until  required.    Nos.  5  and  7  are  the 


Fig.  75. — •'^econd  step  ;  continuing  the  strip. 


INJURIES   TO   THE   PELVIC   FLOOR, 


141 


sizes  used  ;  No.  1  for  the  lower  suture  and  No.  5  for  the  upper  ones. 
Tlie  needles  employed  are  the  ordmary  darning  needles  found  in  the 
dry-c^oods  stores,  vary- 


iiio-  in  leno-th  from 
two  iuelies  and  a  quar- 
ter to  one  inch  and  a 
half.  The  larger  nee- 
dles are  armed  with 
No.  T  thread  and  the 
smaller  with  No.  5. 

To  manipulate 
these  needles  it  is 
necessary  to  have  a 
suitable  forceps,  and 
for  this  I  have  devised 
the  instrument  repre- 
sented by  Fig.  Y7.  It 
is  a  double  forceps. 
The  central  portions 
of  the  two  blades 
which  form  the  han- 
dle are  made  of  spring 
steel.  The  halves  cross 
each  other  at  about  an 
inch  from  each  end 
to  form  the  jaws.  At 
one  end  there  are 
three  grooves  which 
receive  the  needle  and 
hold  it   at    an   acute, 

obtuse,  or  right  angle,  whichever  the  operator  may  require.     The 
other  jaw,  which  closes  over  the  grooved  one,  is  file-faced,  which 


Fig.  'JQ. — Vivifying  complete  ;  r  is  on  tlie  rectocele,  show- 
ing the  appearance  before  the  mucous  membrane  has 
been  lifted  by  the  tenaculum  and  dissected  up. 


Fig.  77. — Needle-forceps. 

keeps  the  needle  from  slipping  through  the  grooves  when  pressure 
is  made  upon  it.  The  jaws  of  the  other  end  are  copper-faced  and 
are  used  to  grasp  the  point  of  the  needle  in  drawing  it  through. 
The  elastic  spring  of  the  handle  portion  opens  the  jaws  at  each 
end,  the  needle  is  introduced  into  the  desired  groove,  the  handle  is 


142 


DISEASES   OF   WOMEN. 


Fig.  78. 


grasped,  wliicli  closes  the  jaws  and  liolds  tlie  needle  perfectly  immov- 
able, no  matter  how  much  pressure  may  be  br(»ii<;lit  to  bear  upon  it. 
When  the  jaws  are  closed  there  is  a  stop-catch  that  holds  the  two 
halves  of  the  handle  together  and  keeps  a  timi  hold  upon  the  needh'. 
The  needle  is  carried  into  the  tissues  while  it  is  held  by  tlie  grooved 
and  tile-faced  jaw ;  it  is  then  unfastened  by  drawing  back  the  catch, 
the  forceps  is  reversed,  and  the  point  of  the  needle  seized  in  the  co}^ 
per-faced  jaws  and  withdrawn.  The  advantage  of  the  coj)])cr- faced 
jaws  is  that  they  seize  the  point  of  the  needle  lirmly 
enough  to  draw  it  through  the  tissues  without  injuring 
the  point ;  a  valuable  feature  in  such  an  instniment. 

The  sutures  are  introduced  as  follows :  The  needle 
— jDlaced  in  the  forceps  at  right  angles  to  it — should  be 
entered  in  the  skin  exactly  at  the  edge  of  the  wound 
at  the  lowest  external  angle  of  the  denuded  tissue.  It 
is  then  passed  outward  deep  into  the  tissues,  then  curved 
round  in  the  tissues  in  front  of  the  rectum  and  deep  into  the  tissue 
of  the  other  side,  and  ___ 

f 


made  to  emerge  at  a 
point  corresponding 
to  the  one  where  it 
was  entered.  If  this 
is  properly  done,  no 
part  of  the  suture  will 
be  seen.  Its  position 
in  the  tissues  will  be 
as  represented  in  Fig. 
78.  The  dotted  line 
represents  the  suture 
which  describes  a  cir- 
cle, and  the  straight 
line  shows  the  sides 
of  the  wound  as  they 


are  brought 


together 


where  the  suture  is 
tied.  Sometimes  when 
the  tissues  are  rigid  it 
is  difhcult  to  introduce 
the  first  suture  with 
one  sweep  of  the  nee- 
dle. It  is  then  better 
to  pass  the  needle  in 


FiQ.  Vf . — The  stitches  in  placa 


INJURIES  TO  THE  PELVIC  FLOOR. 


143 


through  half  of  the  vivified  portion,  to  draw  it  out  and  re-insert  it 
at  the  same  point,  and  to  carry  it  around  througli  the  other  side.  If 
there  is  sutHcient  tissue  between  the  base  of  the  vivilied  ]3art  and 
the  rectum,  the  second  and  third  sutures  may  be  introduced  like  the 
first — each  one  being  passed  at  a  higher  point.  The  fourth  suture 
(see  Fig.  79)  is  introduced  through  the  side.  It  is  then  carried 
through  about  three  eighths  of  an  inch  of  the  vivified  portion  of  tlie 
vaginal  wall,  and  then  passed  through  the  other  side.  The  last  suture 
is  passed  through 
both  sides,  as 
shown  in  Fig.  81, 
the  position  of 
the  sutures  being 
viewed  in  profile. 

When  more 
than  five  sutures 
are  used,  the  fifth 
is  passed  like  the 
fourth,  only  a 
little  above  it. 
Most  operators  in- 
troduce the  in- 
dex-finger into  the  rectum,  to  guide  the  introduction  and  passing  of 
the  needle.  This  should  not  be  done  under  any  circumstances,  be- 
cause, by  so  doing,  the  rectal  wall  is  crowded  forward,  and  is  sure 
to  be  included  in  the  suture,  and,  besides,  it  is  a  violation  of  the 
rules  of  antiseptic  surgery  to  operate  with  dirty  fingers. 

In  many  cases  there  is  very  little  tissue  left  in  the  perineal  body 
after  the  vivifying  is  completed.  The  muscular  coat  of  the  vaginal 
wall  having  become  atrophied,  or  torn  from  its  attachments  to  the 
floor  of  the  pelvis,  there  is  only  the  mucous  membrane  left,  and, 
when  that  is  removed  in  denuding  the  parts,  the  wall  of  the  rectum 
is  all  that  is  left  above  the  skin  and  sphincter-ani  muscle.  When 
such  is  the  case,  the  first  suture  only  should  be  carried  through  the 
tissue,  as  already  described  ;  the  others  should  be  introduced  as 
shown  in  Fig,  79. 

The  great  advantage  of  this  is,  that  the  sides  of  the  wound  are 
brought  together  in  front  of  the  rectum,  the  place  where  the  perineal 
body  should  be.  Furthermore,  the  sutures  introduced  in  this  way 
avoid  the  rectal  wall — a  very  important  desideratum,  as  we  know 
from  the  fact  that  when  any  of  the  sutures  are,  intentionally  or  by 
accident,  passed  into  the  wall  of  the  rectum,  they  cause  much  pain 


Fig.  so. — Laceration  with  rectocele.  (The 
dotted  line  gives  tlie  normal  location 
of  perineal  body.) 


Fig.  8L — Perineal 
body  restored. 
(Profile  view.) 


144  DISEASES  OF   WOMEN. 

ami  rectal  tenesmus,  and  greatly  distress  the  patient,  especiallv  when 
the  bowels  move.  When  the  sutures  are  all  in  place,  the  wound 
should  be  carefully  cleansed  of  all  blood-clots,  and,  if  there  is  still 
some  oozing  of  blood,  traction  should  be  made  upon  the  sutures ;  if 
that  controls  the  bleeding,  the  sutures  should  be  tied  in  the  ordinary 
way.  While  they  are  being  tied  the  sides  of  the  pelvic  lioor  should 
be  pushed  up  by  the  assistants,  to  bring  the  wound  together. 

The  after-treatment  and  other  points,  such  as  the  removal  of 
the  sutures,  will  be  brought  out  in  the  history  of  the  following 
cases : 

Case  of  Central  Laceration  extending  to  the  Sphincter  Ani ;  Uncom- 
plicated.— The  patient,  a  sjiare,  small  woman,  had  always  been  in 
good  general  health.  She  had  been  married  nine  years,  and  had 
one  child  eight  years  old.  liei*  labor  was  easy  and  rapid,  and  her 
convalescence  uninterrupted,  excepting  that  she  had  a  leucorrhoea 
which  began  after  the  lochia  stopped,  and  continued  until  the  time 
wlien  she  sought  medical  advice.  Her  menses  returned  ten  months 
after  her  confinement  and  one  month  after  her  child  was  weaned. 
Six  years  after  her  confinement  she  overtaxed  her  strength,  and  then 
her  leucorrhoea  I)ecame  more  profuse,  and  slie  l)egan  to  suffer  from 
backache  and  slight  pelvic  tenesmus,  especially  upon  standing  or 
walking.  She  was  slightly  constipated,  but  in  all  other  respects  was 
well.  She  sought  medical  advice  because  of  these  symptoms  and  her 
stenlity.  An  examination  showed  a  laceration,  but  no  other  injury 
to  the  pelvic  floor.  The  posterior  and  lateral  parts  of  the  floor  were 
well  sustained,  and  there  was  very  little  separation  of  the  sides  of  the 
laceration.  There  was  commencing  prolapsus  of  the  posterior  vagi- 
nal wall,  but  so  slight  that  it  was  only  apparent  upon  separating  the 
labia  and  causing  the  patient  to  cough  or  make  downward  pressure. 
The  uterus  w\as  slightly  below  its  normal  elevation,  but  not  changed 
in  its  axis.  The  leucorrhoea  was  due  to  a  cervical  catarrh,  which 
promptly  yielded  to  treatment. 

Five  days  after  a  menstrual  period  her  bowels  were  freely  moved 
in  the  morning  by  a  dose  of  ]iulv.  glycyrrhizfe  comp.,  given  at  bed- 
time tlie  night  before.  On  the  following  morning  the  bowels  moved 
spontaneously,  and,  an  hour  later,  an  enema  of  borax  and  wai-m 
water  was  given  to  wash  out  the  rectum.  For  breakfast  she  had  a 
cup  of  cofl^ee  and  a  bowl  of  clear  beef-soup.  A  large  vaginal  douche 
was  used  of  borax  and  hot  water  to  cleanse  the  parts  thoroughly.  At 
twelve,  noon,  she  was  anaesthetized  with  ether,  and  the  operation 
was  performed  according  to  the  method  already  described.  The 
bleeding  was  easily  controlled  by  the  sutures.     A  small  pledget  of 


INJURIES   TO   THE    PELVIC   FLOOR.  145 

nuirino  lint  was  placed  over  the  wound  and  the  knees  bandaged  to- 
o-etlier.  Soon  nausea  followed,  but  no  vomiting,  and  late  in  the  even- 
ing she  was  comfortable,  having  only  a  feeling  of  slight  burning  in 
the  region  of  the  wound.  She  took  a  small  cup  of  tea,  and  slept 
several  hours  during  the  night. 

j^ext  day  she  had  niilk,  soup,  and  gruel.  The  catheter  was  used 
for  the  first  forty-eight  hours,  and  after  that,  when  necessary,  she  was 
rolled  over  upon  her  face,  and,  with  a  bed-pan  ]:)laced  under  her,  she 
urinated  without  further  help.  On  the  morning  of  the  third  day 
she  took  a  Seidlitz  powder,  and  at  noon  an  enema  of  castile  soap  and 
water,  which  moved  the  bowels  freely  and  easily.  After  this  the 
bowels  were  moved  daily  with  an  enema  and  slie  had  her  usual  food. 
The  marine  lint  was  kept  upon  the  outside  of  the  wound  for  five 
days,  changing  it  daily.  There  was  no  discharge  from  the  vagina 
or  wound.  There  were  no  vaginal  injections  used,  and  the  wound 
was  not  washed  at  any  time.  In  fact,  after  the  fifth  day,  she  had  no 
local  treatment.  On  the  eighth  day  the  sutures  were  removed  in 
the  following  way :  She  was  placed  in  Sims's  position  on  the  bed ; 
the  nurse  separated  the  nates,  which  exposed  all  the  sutures  without 
making  any  traction  upon  the  parts ;  each  suture  was  seized  with  a 
forceps,  and,  with  the  tenaculum  blade  of  the  scissors,  one  side  of 
the  thread  was  caught  up  and  divided.     Fig,  82  shows  the  scissors 


Fig.  82 


used  for  the  removal  of  sutures.  It  answers  the  purpose  well,  and 
guards  against  clipping  off  both  ends  and  leaving  the  suture  in  the 
tissues,  an  accident  which  not  unfrequently  happens.  This  method 
of  removing  the  sutures  is  very  much  simpler  than  trying  to  remove 
them  with  the  patient  upon  the  back. 

The  patient  was  kept  in  bed  until  the  twelfth  day  after  the  opera- 
tion, but  during  that  time  she  was  perjnitted  to  change  her  position 
from  the  back  to  either  side  without  help.  On  the  thirteenth  day 
she  was  permitted  to  sit  in  a  chair,  and  on  the  fifteenth  day  she  was 
allowed  to  begin  to  walk. 

Two  months  after  the  operation  she  was  examined,  and  the  space 
11 


14r6  DISEASES  OF   WOMEN. 

between  the  rectum  and  va<^in.i  was  found  to  be  normal  to  the  touch, 
i.  e.,  the  lines  represented  by  the  lower  portion  of  the  posterior  vagi- 
nal wall  and  the  outer  surface  of  the  pelvic  floor,  run- 
ning from  before  backward,  formed  an  angle  as  repre- 
sented at  Fig.  83. 

Furthermore,  when  the  introitus  vagina?  was  re- 
P  tracted  with  a  Sims's  speculum  and  the  instrument  re- 

moved, the  muscles  promptly  contracted  and  firmly 
closed  the  vagina,  showing  that  the  muscles  had  been  restored. 
This  I  consider  to  be  the  only  reliable  evidence  of  the  success  of  this 
operation. 

Laceration  of  the  Pelvic  Floor,  Sphincter-Am  Muscle,  and  Eecto- 
Vaginal  Septum. — In  this  extensive  injury,  in  which  the  laceration 
of  the  walls  t'f  the  rectum  and  vagina  extends  upward  beyond  the 
internal  sphincter  ani,  it  is  necessary  to  restore  the  septum  before 
operating  upon  the  perineum.  As  a  rule,  the  laceration  does  not 
extend  beyond  the  sphincters,  and  the  parts  can  all  be  restored  at 
one  operation,  but  in  the  rare  injury  now  under  consideration,  two 
separate  operations  are  required.  I  will  describe  first  the  operation 
for  restoration  of  the  septum.  The  patient  should  be  placed  in  the 
lithotomy  position,  and  the  anterior  wall  of  the  vagina  elevated  by  i 
a  Sims's  or  bivalve  speculum,  which  exposes  the  parts  to  be  treated. 
The  tissues  on  each  side  of  the  laceration  are  vivified  well  out 
on  the  vagina,  in  order  to  obtain  a  broad  surface  for  coaptation. 
Onls'  enough  of  the  mucous  membrane  of  the  rectum  is  removed 
to  dispose  of  the  scar  tissue  that  may  be  present.  Silk  sutures 
are  introduced  with  a  round-pointed,  curved  needle,  such  as  Emmet 
uses  for  vesico-vaginal  fistula.  The  needle  should  be  introduced 
at  the  outer  edge  of  the  vivified  surface  of  the  vaginal  mucous 
membrane,  and  be  earned  deep  into  the  tissues,  and  should  emerge  I 
just  within  the  edges  of  the  rectal  mucous  membrane.  By  referring 
to  Fig.  86  in  colored  plate  an  idea  may  be  obtained  of  the  sutures  in 
position^  with  this  difference — that  in  this  operation  silk  sutures  are 
used,  and  are  tied  upon  the  vaginal  side,  whereas  in  the  operation  of 
restoring  the  sphincter-ani  muscle  nnd  perinnpum,  catgut  sutures  are 
employed,  and  these  are  tied  upon  the  rectal  side.  The  introduction 
of  the  sutures  is  begun  above,  and  each  one  tied  wlK?n  introduced. 

The  sutures  should  be  Xo.  8  silk,  and  not  more  tlian  an  eighth 
and  a  sixteenth  of  an  inch  apart.  They  should  be  removed  on  the 
eighth  day.  and  one  month  allowed  to  elapse  before  the  next  opera- 
tion is  performed,  in  order  to  give  the  parts  a  chance  to  become 
finnly  united. 


PLATE 


FIG. 84- 


R  L.o    uei 


PLATE   I. 
LaCEKATION    of   the    PERINiEUM    AND    SpHINCTEE    AnI. 

Figure  83.     Page  147. 

The  depressions  on  either  side  of  the  rectal  wall  show  the 
ends  of  the  sphincter  ani.  The  rectum  is  drawn  forward  by 
the  levator. 

Figure  84.     Page  147. 
Denudation  complete. 


INJURIES   TO   THE  PELVIC  FLOOIi.  I47 


OPERATION   FOR   THE   RESTORATION   OF   THE   SPHINCTER 
ANI   AND   PERINEUM. 

It  has  been  already  stated  that  the  cliief  object  of  all  plastic 
operations  upon  the  pelvic  floor  should  be  to  restore  the  muscles 
that  have  been  injured.  This  is  pre-eminently  so  in  the  operation 
to  be  described,  because  the  sphincter  ani  is  the  most  difficult  to 
restore,  and  the  results  of  failure  are  so  apparent  that  neither  the 
surgeon  nor  patient  can  possibly  believe  that  the  operation  is  a  suc- 
cess when  it  is  not — a  delusion  often  indulged  in  regarding  the  j^las- 
tic  operations  to  repair  the  lesser  injuries  of  the  pelvic  floor. 

In  order  to  comprehend  the  position  and  relations  of  the  surfaces 
to  be  vivifled,  it  must  be  borne  in  mind  that  when  the  sphincter  ani 
is  ruptured  the  severed  ends  are  drawn  outward  and  backward  by 
the  retraction  of  the  muscle  until  they  lie  on  either  side  nearly  on 
a  line  with  the  posterior  walls  of  the  rectum.  This  may  be  better 
understood  by  referring  to  Fig.  8-i,  colored  plate.  The  depressions 
on  either  side  of  the  anus  are  the  ends  of  the  muscle  which  are 
drawn  dow^n  below  the  surface. 

The  process  of  vivifying  should  be  begun  by  seizing  the  end  of 
the  muscle  on  the  patient's  left.  With  the  scissors  a  strip  of  tissue 
should  be  removed  from  that  point  around  the  tissues  between  the 
rectum  and  vagina,  and  downward  and  outward  to  and  including 
the  end  of  the  muscle  on  the  right.  When  this  is  done,  it  will 
sometimes  be  found  that  the  softer  tissues  rise  above  the  depressed 
end  of  the  muscle,  so  that  a  fossa  is  formed  on  each  side.  Should 
this  occur,  more  of  the  most  prominent  tissue  should  be  removed. 
The  denudation  is  then  carried  upward  upon  each  side  to  the  point 
where  the  laceration  began.  If  there  is  much  relaxation  of  the 
rectal  and  vaginal  walls,  the  denudation  may  extend  even  higher  on 
the  sides. 

At  this  stage  of  the  vivifying  there  are  two  broad  denuded  sur- 
faces (one  on  each  side)  connected  by  an  isthmus  formed  by  the 
recto-vaginal  walls.  In  this  septum  all  scar  tissue  should  be  cut  away, 
and  then  the  rectal  and  vaginal  walls  should  be  separated  with  the 
handle  of  a  scalpel  or  blunt-pointed  scissors.  The  object  of  this  dis- 
section is  to  give  a  broader  surface  to  be  united,  and  to  permit  the 
vaginal  wall  to  be  raised  up  and  attached  to  the  inner  side  of  the 
perineal  body,  as  it  is  called.  When  the  vivifying  is  completed,  the 
parts  appear  as  represented  in  Fig.  85,  colored  plate.  There  are  or- 
dinarily two  sets  of  sutures  used,  one  to  coaptate  the  rectal  wall  and 
sphincter-ani  muscle,  and  the  other  to  do  the  same  for  the  periueeum. 


148  DISEASES  OF   WOMEN. 

The  rectal  sutures  are  introduced  first.  I  use  No.  2  catgut  and  tL- 
cun-ed  Emmet  needle.  The  needle  is  entered  at  the  margin  of  tli. 
rectal  mucous  membrane  on  the  patient's  right  side,  and  is  carried 
upward  and  outward  in  the  tissues  about  a  quarter  of  an  inch.  It 
is  then  withdrawn,  and  entered  on  the  left  side,  and  brought  out  in 
a  manner  corresponding  to  the  course  which  the  needle  traversed  ii 
the  right  side.  This  leaves  the  ends  of  the  suture  to  be  tied  on  tli< 
inside  of  the  rectum. 

In  introducing  the  first  perineal  suture,  the  point  of  the  needl< 
should  be  entered  at  the  inner  and  lower  point  of  the  vivified  sur- 
face, then  carried  outward  around  the  end  of  the  muscle,  then  in- 
ward through  the  recto-vaginal  wall,  and  finally  around  the  other 
end  of  the  muscle  to  a  point  directly  opposite  the  one  where  the 
needle  was  introduced.  This  requires  f-kill  and  practice,  and  is  often 
diflicult ;  and  I  have  found  it  easier  to  pass  the  needle  around  the 
ends  of  the  muscle  and  bring  it  out  in  the  median  line,  reintroduce 
it,  and  carry  it  around  the  other  end  of  the  muscle.  The  objection 
made  to  this  method  is  that  the  central  portion  of  the  suture  is  ex- 
posed, but  the  suture  is  completely  buried  in  the  tissues  when  it 
is  tied.  Certainly  it  is  better  to  introduce  the  first  suture  accurately 
in  this  way  than  to  attempt  the  more  difficult  way  and  fail  to  get  it 
right,  a  result  usual  to  those  who  are  not  accustomed  to  this  operation. 
The  second  suture  may  be  introduced  in  the  same  way.  The  remain- 
ing sutures  are  employed  in  the  way  described  in  the  operation  for 
restoring  the  laceration  in  the  first  degree.  Fig.  S6,  colored  plate, 
shows  the  sutures  in  place. 

Certain  changes  are  necessary  to  be  made  in  the  details  of  the 
operation  in  those  rare  cases  in  which  the  laceration  of  the  recto- 
vaginal septum  has  extended  so  high  up  that  an  operation  for  it.- 
restoration  is  necessary  before  restoring  the  sphincter-ani  muscle  and 
the  perinseum.  Another  condition  requiiing  similar  treatment  is 
found  in  cases  in  which  the  septum  has  been  extensively  lacerated, 
but  has  united  by  intervening  scar  tissue,  which  has  to  be  removed 
to  secure  a  perfect  restoration. 

Under  such  circumstances,  and  also  in  cases  in  which  the  rectal 
and  vaginal  walls  can  not  be  separated  by  dissection,  it  is  better  to 
unite  the  vaginal  wall  in  the  median  line  by  a  special  row  of  sutures 
running  parallel  to  the  axis  of  the  vagina.  In  such  cases  three  sets  of 
sutures  are  necessary :  One  to  unite  the  rectal  wall,  one  to  unite  tho 
perinaeum,  and  one  to  unite  the  vaginal  wall.  In  performing  this 
modified  operation,  I  usually  vivify  the  edges  of  the  laceration  of  the 
septum  the  entire  length  and  then  introduce  the  rectal  sutures  and  be- 


PLATE   II. 

Operation  for  Laceration  of  the  Perineum. 

Figure  85.     Page  148. 
Sutui'es  in  the  recto-vaginal  septum  introduced. 

Figure  86.     Page  148. 
Sutures  in  the  septum  tied.     The  remaining  sutures  in  place. 


PLATE 


FIG. 86 


R    L.D.   DEL 


INJURIES   TO   THE  PELVIC  FLOOR.  149 

fore  tying  tlieni  vivify  all  the  rest  of  the  parts  to  be  united.  The 
stitclies  are  introduced  into  the  vaginal  wall  and  the  perineal  stitches 
placed  last.  The  patient  is  put  into  Sims's  position  and  the  rectal 
sutures  are  tied.  She  is  replaced  upon  the  back  and  the  vaginal 
sutures  are  tied,  and  lastly  those  in  the  joelvic  floor. 

I  have  obtained  the  very  best  results  from  this  method  of  opera- 
ting, and  in  suitable  cases  prefer  it  to  all  others.  Further  details  of 
the  operations  will  be  brought  out  in  the  following  history  of  cases : 

Typical  Case  of  Laceration  extending  through  the  Sphincter  Ani. — 
The  patient  was  twenty-six  years  old  when  she  was  confined  with 
her  first  child.  The  labor  was  tedious,  and  she  was  delivered,  with 
forceps,  of  a  very  large  child,  which  died  during  delivery.  She 
made  a  rather  slow  recovery,  owing  to  the  extensive  injury  to  the 
floor  of  the  pelvis.  Five  months  after  confinement  I  saw  her  for 
the  flrst  time.  She  was  then  in  very  good  health,  but  suffered  pain 
in  the  region  of  the  injury,  especially  when  she  walked,  and  she  had 
xery  little  control  of  the  rectum.  When  constipated,  she  suffered 
very  little;  but,  when  the  bowels  were  free  and  when  there  was 
flatulence,  she  was  obliged  to  remain  secluded. 

I  found  that  the  laceration  involved  the  sphincter-ani  muscle, 
and  evidently  had  extended  upward  into  the  wall  of  the  rectum  and 
vagina ;  but  union  had  taken  place,  by  a  little  intervening  scar  tis- 
sue, down  to  the  sphincter,  or  within  a  quarter  of  an  inch  of  it.  The 
muscles  of  the  pelvic  floor,  excepting  the  sphincter  and  transver- 
sus  jDerinsei,  acted  well,  and  held  tlie  divided  sides  well  up.  The 
end  of  the  rectum  was  also  drawn  upward  and  forward,  so  that  the 
distance  from  the  vestibule  to  the  posterior  margin  of  the  anus  was 
less  than  normal.  This  brought  the  posterior  wall  of  the  vagina  up 
to  the  anterior,  so  that  the  vagina  was  closed.  It  was  only  by  plac- 
ing the  finger  in  the  rectum  and  pressing  it  backward  that  the  full 
extent  of  the  laceration  became  apparent.  She  was  constipated,  and 
her  tongue  slightly  coated,  at  this  time.  Pil.  hydrarg.,  gr.  x,  and 
pulv.  ipecac,  gr.  j,  were  given  at  bedtime,  and  a  wine-glass  of  Hun- 
yadi-Janos  water  an  hour  before  breakfast  next  morning.  This 
moved  tlie  bowels  freely,  and  they  were  kept  free  for  the  subsequent 
two  weeks  with  the  following : 

Fluid  extract  of  podophyllum 3  j  ; 

Tincture  of  colocynth 3  ij ; 

Tincture  of  belladonna 3  j  ; 

Glycerin o  ss. ; 

Syrup  of  acacia  and  compound  tincture  of  cardamom., 
of  each §  j. 


150  DISEASES  OF   WOMEN. 

A  tcaspoonfui  of  this  iioou  aud  evening  before  meals.     "When  this 
acted  too  freely,  only  one  dose  was  given. 

During  these  two  weeks  the  nurse  passed  the  finger  every  day 
into  the  rectum  and  pressed  the  parts  back  toward  the  coccyx,  main- 
taining the  traction  steadily  for  several  minutes.  This  was  done  for 
the  purpose  of  restoring  the  elasticity  of  the  tissues,  and  also  elon- 
gating the  divided  sphincter  muscle  as  much  as  possible.  Menstrua- 
tion then  began,  and  no  further  local  treatment  was  employed  until 
after  it  stopped,  when  it  was  resumed.  Four  days  after  the  mensor- 
ceased,  the  operation  was  performed  in  the  jjrescribed  way,  silk 
sutures  being  used.  For  twenty-four  hours  before  the  operation, 
and  for  three  days  after,  the  patient  had  only  fluid  food — Ijeef-tea, 
strained  soups,  whey,  and  water.  After  the  third  day,  peptonized 
milk,  strained  oatmeal  and  barley  graels,  and  raw  oystei-s  were  added 
to  the  diet  list. 

There  was  sufficient  pain  during  the  first  three  days  to  require 
ten  drops  of  liquor  opii  com  p.  to  be  taken  every  four  hours.  On 
the  fourth  day  she  suffered  from  flatulence,  which  was  relieved  by 
catheterizing  the  rectum,  using  a  silver  catheter ;  this  had  to  be  re- 
peated the  following  day.  On  the  eighth  day  (and  before  the  su- 
tures were  removed)  half  an  ounce  of  sulphate  of  magnesia  in 
peppermint-water  was  given  before  brealcfast  and  toward  noon ; 
when  the  patient  felt  the  bowels  inclined  to  move,  half  a  pint  of 
solution  of  ox-gall  and  water  were  used  as  an  enema.  When  this 
had  been  retained  about  twenty  minutes,  the  nurse  assisted  the 
evacuation  of  the  bowels  by  making  pressure  upon  each  side  of  the 
wound  opposite  the  flrst  suture,  and,  with  the  index-linger  of  the 
other  hand  in  the  vagina,  she  made  gentle  and  interrupted  pressure 
downward  and  outward.  In  this  way  it  was  hoped  that  the  rectum 
would  be  evacuated  without  disturbing  the  wound.  There  was  not 
the  slightest  trace  of  hcemorrhage,  which  gave  reason  for  believing 
that  no  harm  had  been  done. 

On  the  ninth  day  all  the  sutures  were  removed,  and  on  the  tenth 
day  the  bowels  were  moved  in  the  same  way  as  before.  During  all 
this  time  the  catheter  was  used  to  draw  the  urine.  After  this  the 
patient  was  permitted  to  urinate  in  the  prone  position.  Every  second 
day  until  the  twentieth  the  bowels  were  moved,  the  same  care  being 
taken  by  the  nurse  to  guard  the  wound  during  the  evacuation.  On 
the  twentieth  day  the  wound  was  carefully  examined,  and  there  was 
apparently  perfect  union  throughout,  including  the  mucous  mem- 
brane. The  function  of  all  the  muscles  of  the  pelvic  floor  was  re- 
stored, except  that  of  the  sphincter  ani.     The  function  of  that  mus- 


INJURIES  TO   THE   PELVIC   FLOOR.  151 

cle  was,  however,  sulHcientlj  restored  to  give  the  rectum  retaining 
power,  but  it  did  not  act  as  a  perfect  sphincter  muscle.  When  it 
acted,  the  contraction  was  not  equally  toward  the  center,  but  rather 
toward  the  point  of  rupture  that  had  been  restored.  The  posterior 
portion  of  the  perineal  body  acted  lilce  a  lixed  point,  toward  which 
the  nuiscle  contracted.  I  am  inclined  to  believe  that  this  is  the  best 
result  that  can  be  obtained  by  this  operation.  After  the  new  repara- 
tive tissue  which  is  developed  during  healing  has  fully  contracted, 
the  function  of  the  muscle  becomes  more  nearly  restored.  Indeed, 
it  is  in  many  cases  quite  perfect  so  far  as  controlling  the  rectum  is 
concerned,  but  it  rarely,  if  ever,  acts  exactly  as  it  did  before  injuiy 
— i.  e.,  by  a  perfect  concentric  contraction. 

A  Case  illustrating  Partial  Failure  of  the  Operation;  a  Second 
Operation  completing  the  Cure. — The  patient  was  thirty-five  years 
old,  and  had  had  three  children.  The  youngest  was  eighteen  months 
old  at  the  thne  when  this  history  was  taken.  Her  fii'st  labor,  five 
years  and  a  half  ago,  was  complicated.  The  patient  stated  that  the 
doctor  in  attendance  said  that  there  was  a  shoulder  presentation,  that 
the  child  was  turned  and  delivered  feet  first,  and  that  the  forceps 
was  used  to  deliver  the  after-coming  head.  From  that  time  onward 
she  had  no  control  of  the  rectum,  and  the  only  way  she  w\as  able  to 
take  care  of  herself  was  by  being  extremely  constipated,  the  bowels 
never  moving  except  in  response  to  medicine,  a  dose  of  which  she 
usually  took  about  once  every  week.  The  extent  of  the  injury  was 
exactly  like  the  case  last  given,  excepting  that  there  was  union  of  a 
thin  band  of  vaginal  mucous  membrane,  which  extended  outward  to 
the  upper  margin  of  the  sphincter-ani  muscle.  There  were  also  two 
hicmorrhoidal  tumors,  formed  by  hyperplasia  of  the  rectal  mucous 
membrane,  located  at  each  side  of  the  anus.  These  haemorrhoids, 
which  ai*e  not  uncommon  in  this  injury,  were  removed  one  month 
before  the  restoration  of  the  lacerated  parts  was  undertaken.  The 
mode  of  operating  was  by  seizing  the  tumors  in  a  Pean  forceps  and 
making  traction  sufiicient  to  raise  the  mucous  membrane,  then  pass- 
ing the  hsemorrhoid-clamp  (Fig.  87)  beneath  the  forceps,  and  slowly 


Fig,  87. — HasDiorrhoid  clamp. 


152  DISEASES  OF   WOMEN. 

constricting  the  pedicle  by  tit^litening  the  clamp.  A  ligature  of 
prepared  silk  was  ii])plie(l  to  the  pedicle  under  the  clamp.  The  for- 
cej)s  aud  clauij)  were  then  removed,  the  tumor  clipped  oli'  far  enough 
outside  of  the  ligature  to  prevent  its  slipping,  and  tlie  stump  touched 
with  carbolic  acid.  The  ligatures  came  oif  in  less  than  a  week,  leav- 
ing a  very  minute  spot  to  heal.  She  was  then  submitted  to  about 
the  same  preparatory  treatment  as  in  the  last  case  related,  and  the 
operation  was  performed  as  before  described.  The  <]iet  was  gruel 
and  peptonized  milk,  with  beef-tea.  On  the  second  day  half  an  ounce 
of  Rochelle  salt  was  given,  followed  in  three  hours  by  an  enema  of 
half  a  pint  of  a  solution  of  ox-gall,  and,  one  hour  later,  a  large  ene- 
ma of  soap-suds.  This  did  not  move  the  bowels ;  on  the  following 
morning  lialf  an  ounce  of  castor-oil  was  given,  and  in  the  afternoon 
the  enema  repeated  as  on  the  previous  day ;  the  enema  came  away, 
but  the  bowels  did  not  move.  The  next  day,  she  was  ordered  a 
mixture  composed  of  a  decoction  of  senna,  one  ounce  to  a  pint  of 
water,  wath  one  ounce  of  Roclielle  salt.  Of  this,  two  ounces  were 
given  every  hour  until  she  had  taken  three  doses.  It  produced  a 
free  evacuation,  without  causing  pain  in  the  wound  or  doing  it  any 
harm.  The  mixture  was  repeated  in  the  same  way  with  a  like  effect, 
and  was  again  ordered  a  third  time,  but,  by  an  oversight  of  the  nurse 
(the  case  was  in  a  general  hospital),  it  was  not  given.  Another 
mistake  was  made  the  following  day,  the  nurse  giving  two  drachms 
in  place  of  two  ounces  of  the  medicine.  On  the  eighth  day  after 
the  operation  the  medicine  was  given  correctly  ;  but,  when  the  bowels 
were  about  to  move,  the  nurse,  who  should  have  supported  the  parts, 
was  absent,  and  the  patient  got  out  of  bed  to  use  the  commode,  and 
had  a  free  movement,  attended  with  pain  and  some  bleeding.  Up  to 
this  time  the  wound  had  progressed  quite  well  in  healing,  but  that 
unfortunate  movement  of  the  bowels,  unaided  by  the  nurse,  tore  the 
ends  of  the  sphincter-ani  muscle  apart,  and  spoiled  the  operation  to 
that  extent.  On  the  tenth  day  the  sutures  were  removed.  There 
was  perfect  union,  excepting  the  ends  of  the  nmscle.  The  opera- 
tion was  a  complete  failure,  so  far  as  its  main  object  was  coucerned. 
She  was  kept  in  the  hospital  for  two  days  more,  when  it  was  found 
that,  although  her  bowels  were  easily  kept  regular — a  great  improve- 
ment on  her  former  state — she  had  very  little  more  control  of  the 
rectum  than  before  tiie  operation. 

Three  months  after  this  she  was  again  persuaded  to  try  to  obtain 
relief,  and  she  was  placed  under  the  care  of  a  more  competent  nui*se, 
who  followed  directions  regarding  pi-eparatory  treatment,  including 
the  manipulation  daily  of  the  sphincter  ani,  and  at  the  end  of  a  week 


INJURIES    TO   THE   PELVIC   FLOOR. 


153 


another  operation  was  performed  to  restore  the  sphiucter.  The 
stretching  of  the  mnscle  backward  with  the  finger  in  tlie  rectum  as 
practiced  b}'  the  nurse  was  more  effectual  than  in  cases  in  which  the 
nipture  is  complete.  The  part  of  the  pelvic  floor  which  was  restored 
by  the  operation  gave  some  support  to  the  severed  ends  of  the  sphinc- 
ter, so  that  when  traction  backward  was  made  the  muscle  became 
cousiderably  elongated  ;  and  when  the  second  opei*ation  was  under- 
taken the  parts  were  sufflciently  relaxed  to  facilitate  the  necessary 
manipulations. 

The  patient,  well  anaesthetized,  was  placed  in  Sims's  position,  a 
small  speculum  introduced  into  the  rectum  posteriorly,  and  traction 
made  backward,  while  with  a  strong  tenaculum,  fixed  in  the  margin 
of  the  anus  anteriorly,  the  ends  of  the  muscle  and  the  intervening 
tissues  were  brought  into  view.  The  end  of  the  muscle  of  the  left 
side  was  seized  in  the  tissue  forceps  and  denudation  made  from  the 
left  to  the  right  end  of  the  muscle.  The  vivifying  includad  both 
ends  of  the  muscle  and  extended  upward  on  the  anterior  rectal  wall 
about  half  an  inch.  The  sutures,  three  in  number,  were  introduced 
in  the  same  way  as  in  the  first  operation.  Some  trouble  was  ex- 
perienced in  curving  the  needle  around  through  the  tissues,  but  with 
the  aid  of  an  assistant,  who  passed  his  index-finger  into  the  vagina 
and  everted  the  rectum  in  front,  all  the  sutures  were  accurately  in- 
troduced. 

On  the  third  day  after  the  operation  a  dose  of  senna  and  salts 
was  given  in  the  morning,  and  at  noon  the  bowels  were  moved  in  a 
rather  novel  way.  An  apparatus  constructed  upon  the  principle  of 
that  used  by  Professor  Bigelow  for  expelling  fragments  of  stone 
from  the  bladder  was  employed  to  wash  out  the  contents  of  the  rec- 
tum (Fig.  88). 


Fio.  88. — A  is  a  hard-rubber  rectal  tube  bifurcated  at  b  c ;  b,  which  is  the  supply  tube, 
is  attached  to  a  iountain  syringe,  and  c  connects  with  the  evacuator,  composed  of  a 
soft-rubber  bulb,  with  an  escape  tube.  In  other  words,  it  is  a  large  reflux  catheter 
with  a  rubber  bulb  in  the  escape  tube  for  tlie  purpose  of  facilitating  the  outflow. 

Two  nurses  use  this  instrument  as  follows :  One  passes  the  tube 
into  the  rectum,  carefully  making  continuous  pressure  backward  to 
avoid  pressing  upon  the  edges  of  the  wound,  while  the  other  nurse, 


154  DISEASES   OF   WOMEN. 

closing  tlie  escape  tube  and  opening  the  stop  in  tlie  fountain  syringe, 
injects  the  sohition  of  soap  and  water.  AVhen  half  a  ]>int  ha.s  been 
introduced,  the  supply  is  cut  off  and  the  evacuation  tube  opened. 
If  the  contents  of  the  rectum  do  not  flow  out,  the  bulb  is  pressed 
and  relaxed  after  the  manner  of  using  a  Davidson's  syringe.  This 
process  is  repeated  until  the  bowels  are  freely  evacuated.  The  bow- 
els were  moved  in  this  way  until  the  twelfth  day  (the  sutures  were 
removed  on  the  ninth) ;  after  that  the  bowels  were  moved  daily  by 
the  senna  and  salts.  At  the  end  of  three  weeks  the  restoration  of 
the  muscle  was  as  perfect  as  could  be,  and  the  patient  was  dismissed 
with  complete  retaining  power. 

This  case  illustrates  tlie  danger  there  is  of  the  ends  of  the  sphinc- 
ter muscle  being  torn  apart  when  the  bowels  are  moved.  A  skilled 
nurse,  well  used  to  the  management  of  such  cases,  can  do  much  to 
avoid  this  unfortunate  accident,  and  yet  when  all  care  is  exercised  it 
will  often  happen.  In  order  to  avoid  this,  several  ways  have  been 
tried.  Keeping  the  bowels  contined  for  ten  or  twelve  days  was  the 
fashion  for  a  long  time.  More  recently  some  operators  have  kept 
the  bow^els  free  by  laxatives  that  rendered  the  contents  fluid  and  pro- 
cured an  evacuation  every  day  after  the  second  day  from  the  opera- 
tion. I  have  tried  both,  and  now  prefer  the  reflux-catheter  evacuator 
when  a  nurse  can  be  obtained  who  knows  how  to  use  it.  "When 
this  is  net  possible,  I  prefer  to  keep  the  contents  of  the  bowels  solu- 
ble and  to  move  them  every  second  day — beginning  on  the  third  day 
after  the  oj^eration. 

When  union  is  obtained,  excepting  of  the  sphincter  muscle,  as  in 
the  case  just  related,  and  a  second  operation  is  performed,  some  op- 
erators prefer  to  begin  de  novo^  dividing  the  united  ])oi'tion  and  then 
proceeding  as  in  the  primary  operation.  I  much  jirefer  to  keej>  all 
that  has  been  gained  and  to  restore  the  sphincter  in  the  way  already 
described.  I  was  flrst  induced  to  adopt  this  method  in  a  case  that 
had  been  twice  operated  upon  before  it  came  to  me  with  the  result 
of  restoring  all  but  the  sphincter.  So  much  tissue  had  been  removed 
that  I  dared  not  risk  a  possible  complete  failure,  hence  I  attempted 
to  restore  the  sphincter  in  the  way  just  described,  and  with  success. 
My  second  case  of  this  kind  was  one  in  which  complete  laceration 
occurred  during  labor ;  primary  union,  without  sutures,  of  the  peri- 
neal body  took  place,  but  not  of  the  sphincter.  Since  then  I  have 
repeatedly  operated  successfully  in  such  cases  of  paitial  failure  in  my 
own  practice  and  that  of  others, 


INJURIES   TO   THE   PELVIC   FLOOR.  155 


OPERATION  FOR  RESTORATION  OF  THE  PELVIC  FLOOR  IN 
SUBCUTANEOUS  LACERATION  BETWEEN  THE  VAGINA  AND 
RECTUM. 

This  operation  is  the  same  as  when  the  laceration  involv^es  the 
skin  and  mucous  membrane  also,  excepting  that  the  whole  of  the 
skin  and  mucous  membrane  occupying  the  position  of  the  perineal 
body  is  removed.  Before  beginning  the  denudation  the  tissues  in 
front  of  the  sphincter  should  be  seized  between  the  thnmb  and  finger. 
This  will  indicate  the  extent  to  which  they  should  be  removed^ 
"While  the  parts  are  thus  held  in  the  finger  and  thumb,  or  with  a 
tissue  forceps,  the  whole  mass  should  be  removed  with  one  sweep  of 
the  curved  scissors.  After  this  is  done,  if  there  is  still  some  loose 
tissue  lying  over  the  muscular  structures  below  and  on  either  side,  it 
should  be  removed.  The  sutures  are  introduced  as  in  the  ordinary 
operation,  special  care  being  taken  to  pass  the  sutures  deep  into  the 
muscular  tissues,  and  to  use  plenty  of  them.  At  the  present  time  I 
see  accounts  in  the  journals  of  restoring  the  perinseum  with  one  su- 
ture. I  have  seen  some  of  these  so-called  restorations,  and  found 
the  results  utterly  useless, 

A  Typical  Case  of  Subcutaneous  Laceration,  belonging  to  the  Sec- 
ond Class  described  in  the  Classification. — This  patient  was  the  wife 
of  a  physician ;  1  give  the  history  as  I  obtained  it  from  her  hu,s- 
band. 

The  patient  was  thirty-three  years  of  age,  the  mother  of  two  chil- 
dren ;  the  first  born  on  March  29,  1880,  and  lived  eleven  hours;  sec- 
ond born  September  9,  1881,  now  living;  and  one  miscarriage  since 
the  operation  in  February,  1884. 

The  first  labor  was  tedious,  lasting  from  Friday  at  S  a.  m.  till 
Monday  at  2  p.  m. — seventy-eight  hours,  but  accompanied  with  no 
after  ill-effects  of  any  note.  In  the  second  labor,  though  it  was 
normal  in  duration,  from  its  inception  until  the  completion  of  the 
first  stage  it  was  observed  that  the  presenting  head  was  very  low  in 
tlie  pelvis,  resting  upon  the  posterior  wall  of  the  vagina,  while  the 
cervix  was  directed  toward  the  hollow  of  the  sacrum,  and  was  un- 
evenly dilated,  the  anterior  lip  being  much  thicker  than  the  posteri- 
or. As  the  head  descended  toward  the  vulva  the  recto- vaginal  tis- 
sues were  pushed  before  it  and  extended  beyond  the  vulva  on  the 
periucieum.  The  anterior  segment  of  the  cervix,  descending  in  front 
of  the  head  and  tightly  grasping  it,  had  to  be  pushed  upward  in  the 
interval  between  tlie  expulsive  pains  and  held  until  complete  exten- 
sion occurred  and  the  delivery  was  com])leted.     Nothing   of   note 


156  DISEASES   OF   WOMEN. 

transpired  during  the  Ijing-in  period  of  sixteen  days,  excepting  great 
difficulty  in  moving  the  bowels. 

Tpon  taking  an  upriglit  position,  it  was  found  that  the  protni.sion 
or  prohii)se  wliich  was  noticed  at  tlie  time  of  deHvery  was  still  pres- 
ent, and  complaint  was  made  of  the  feeling  that  "  everything  was 
falling  out '' ;  from  this  time  onward  defecation  could  (>n]\  be  accom- 
plished by  pushing  the  protruding  mass  well  back  into  the  vagina. 
Her  subsequent  health  was  bad ;  rapid  loss  of  flesh  and  strength  fol- 
lowed ;  nervous  prostration,  impaired  digestion,  and  loss  of  appetite  su- 
pervened, totally  incapacitating  her  for  her  usual  duties.  ( )ue  month 
after  confinement  she  had  a  very  painful  attack  of  mastitis,  which, 
however,  did  not  go  on  to  the  stage  of  suppuration,  but  further  pros- 
trated her,  accompanied  as  it  was  by  aphtlue,  ulceration  of  the  cornea, 
facial  neuralgia,  etc.  These  sequelae,  together  with  over-lactation,  car- 
ried on  for  fourteen  months,  naturally  first  retarded  and  then  pre- 
vented the  proper  involution  of  the  pelvic  organs  ;  and  the  prolapse  of 
the  recto-vaginal  wall,  dragging  do"wn  the  heavy  utenis,  caused  constant 
distress,  pain,  and  suffering,  both  physical  and  mental.  Constipation 
of  the  most  intractalde  kind  now  existed,  and  the  bowels  could  only  be 
evacuated  by  liquefying  their  contents  with  purgatives  aided  by  enemas. 

Examination  made  twelve  months  after  confinement  revealed  a 
slight  prolapse  of  the  anterior  vaginal  wall,  bladder,  and  urethra,  and 
extensive  prolapse  of  the  posterior  wall,  which  caused  the  rectum  to 
be  drawn  forward  through  the  ostium,  forming  a  sacculus.  The 
uterus  was  three  and  one  fourth  inches  in  depth  and  retroverted. 
The  mucous  membrane  of  the  vaccina  and  the  inteo:ument  of  the 
pelvic  floor  presented  no  appearance  of  having  been  ru]itured  at  any 
time,  but  there  was  not  a  sign  of  any  muscle  or  fascia  in  the  center 
of  the  space  between  the  vagina  and  rectum. 

J/«y  10,  1883. — (The  operation  was  performed  in  the  way  de- 
scribed above.  The  following  is  added  to  the  doctor's  report  by  the 
author.) 

After  rallying  from  the  anaesthetic,  great  pain  at  the  seat  of  the 
upper  stitch  was  comi)lained  of,  necessitating  the  free  use  of  opium 
to  allay  it.  For  eight  days  the  urine  was  drawn  by  catheter,  the 
patient  being  unable  to  void  it  at  any  time  when  lying  in  the  dorsal 
position.  Twenty-four  hours  after  tiie  ojieration  the  Ix^wels  were 
readily  moved  by  a  single  enema,  and  for  several  days  acted  without 
resort  to  any  provocative.  Two  of  the  sutures  were  removed  on  the 
eighth  day  and  the  others  on  the  tenth  day.  Perfect  union  existed 
throughout,  and  three  weeks  fi-om  the  day  of  the  operation  the  jia- 
tient  was  up  and  around  the  room. 


INJURIES  TO  THE   PELVIC   FLOOR.  157 

From  this  time  on  tue  im])rovemc'ut  in  every  particular  has  been 
rapid  and  uuinterrnpted,  with  an  entire  disap])earanee  of  tlie  pro- 
lapse, though  the  uterus  remains  considerably  retrovei-ted,  which 
position  it  had  occupied  for  years  before  the  marriage  of  the  patient. 
At  this  time,  fourteen  months  after  the  operation,  there  has  been  no 
return  of  the  former  ti'ouble,  though  she  performs  all  her  domestic 
duties  and  can  exercise  without  fatigue  or  distress.  At  the  time  of 
making  this  report  she  weighs  over  twenty  pounds  heavier  than  she 
(lid  one  year  ago,  and  to  every  appearance  is  in  perfect  health. 

Median  Laceration  down  to  the  Sphincter  Ani,  complicated  with 
Temporary  Relaxation  of  all  the  Muscles  of  the  Pelvic  Floor,  and  Pro- 
lapsus of  the  Recto-Vaginal  Walls. — The  patient  was  twenty -seven 
years  old,  well  developed,  and  in  good  general  health.  She  had  been 
married  four  years.  She  had  had  two  children,  the  first  sixteen 
months  old  and  the  second  five  months.  Her  second  labor  was 
tedious  and  difiicult ;  the  cause  unknown.  Two  weeks  after  her  last 
confinement  she  entered  actively  upon  her  household  duties,  and 
very  soon  afterward  began  to  suffer  from  pelvic  tenesmus,  which  was 
much  aggravated  by  the  erect  position.  Being  of  an  active  dispo- 
sition, she  persisted  in  attending  to  her  duties  until  her  discomfort 
became  so  great  that  she  was  obliged  to  seek  relief.  "When  first  ex- 
amined, she  said  that  in  standing  and  walking  she  was  tormented 
with  a  feeling  of  dragging  downward  in  the  pelvis,  and  lately  had 
felt  "something  protmding  from  the  vagina  while  in  the  erect  po- 
sition." Her  bowels  had  usually  been  regular,  but  lately  she  noticed 
that  they  moved  with  difliculty,  as  if  there  was  some  loss  of  expelling 
power,  and  when  voluntary  efforts  were  made  to  evacuate  the  recturu. 
the  recto- vaginal  walls  protruded. 

All  these  symptoms  were  much  reKeved  upon  lying  down.  She 
weaned  her  child  when  it  was  three  months  old,  because  she  had  not 
much  milk,  and  her  friends  made  her  believe  that  her  suffering  was 
due  to  nursing.  At  the  fourth  month  she  menstmated,  but,  not 
being  any  better,  she  sought  advice.  The  laceration  Avas  found  to 
be  as  ah'eady  stated.  The  transversus-perinsei  muscles  were  still 
attached  to  the  sides  of  the  laceration,  and  by  drawing  the  parts  out- 
ward the  vagina  was  distended  laterally  as  well  as  antero-posteriorly. 
The  distance  from  the  vestibule  to  the  anus  was  increased  by  the 
downward  and  backward  displacement  of  the  posterior  portion  of 
the  pelvic  floor.  The  posterior  rectal  wall  and  the  anterior  vaginal 
wall  were  found  lying  upon  the  sphincter-ani  muscle,  and  when 
the  patient  coughed  or  strained  they  protruded  a  little  beyond  the 
liue  of  the  anus.     There  was  also  commencing  prolapsus  of  the  base 


15S  DISEASES   OF   WOMEN. 

of  the  bladder  and  anterior  vaginal  wall.  By  passing  a  large  sound 
into  the  rectum  it  was  found  that  the  recto-vaginal  walls,  imme- 
diately above  the  sphincter-ani  muscle,  were  very  tliin,  indicating 
that  the  muscular  coat  of  the  vagina  had  been  torn  hjngitudinally,  or 
else  that  its  attachment  to  the  muscles  of  the  pelvic  floor  had  been 
severed  ;  perhaps  both  injuries  had  occurred. 

The  patient  was  prepared  for  the  operation  in  the  same  way  as 
in  the  case  just  related.  The  denudation  was  made  in  the  usual  man- 
ner, but  was  carried  upward  on  each  side  nearly  half  an  inch  above 
the  outline  of  the  scar  of  the  original  laceration  and  about  three 
quarters  of  an  inch  broad  from  without  inward.  The  nuicous  mem- 
brane was  also  removed  upon  the  vaginal  wall  up  to  the  point  where 
it  came  in  contact  with  the  anterior  vaginal  wall ;  that  was  made  the 
apex  or  most  prominent  point  of  the  \avifying.  This  was  much  be- 
yond the  limits  of  the  laceration.  The  object  in  vivifying  the  tis- 
sues so  high  up  on  either  side  was  to  secure  the  ends  of  the  bulbo- 
cavernosus  muscle  in  the  wound  in  order  to  reunite  them,  and  for  a 
like  reason  the  vivifying  was  made  high  up  on  the  vaginal  wall  in  the 
hope  of  uniting  its  muscular  coat  to  the  muscles  of  the  pelvic  floor. 
When  the  parts  to  be  united  were  vivified  it  was  found  that  all  that 
remained  of  the  vaginal  wall  at  that  point  had  been  removed,  leaving 
nothing  but  the  rectal  wall.  This  was  not  owing  to  liaving  removed 
too  mucli  tissue,  but  because  ths  muscular  coat  of  the  vagina  had 
been  destroyed  by  the  original  injuiy.  There  was  free  haemorrhage, 
especially  from  the  veins  in  the  deep  portion  of  the  wound,  but  the 
sutures  controlled  it.  The  first  suture  was  passed  around  wholly 
within  the  tissues,  but  the  next  ones  were  passed  deep  in  on  one 
side,  then  out  and  across  in  front  of  the  rectum,  and  finally  througli 
the  other  side,  the  object  being  to  bring  the  sides  of  the  wound  to- 
gether in  front  of  the  rectum.  The  fifth  and  sixth  sutures  were 
passed  through  each  side  and  through  the  middle  coat  of  the  vagina, 
and  the  seventh  through  the  sides  only. 

After  tying  the  sutures  and  placing  marine  lint  over  the  wound, 
an  abdominal  bandage  was  applied,  and  a  narrow  perineal  bandage 
attached  to  it  and  fastened  rather  firmly.  When  the  patient  recov- 
ered from  the  ether  she  had  vomiting,  which  lasted  into  tlie  night ; 
she  also  had  sharp  pain,  which,  toward  the  moraing  of  the  follo^nng 
day,  was  accompanied  with  severe  rectal  tenesmus.  This  prevented 
lier  from  sleeping,  and  made  her  quite  weary.  The  pain  and  tenes- 
mus were  caused,  I  am  sure,  by  the  fact  that  one  or  more  of  the 
sutures  was  passed  through  a  portion  of  the  rectal  wall.  I  took 
pains  to  avoid  the  rectum,  but  must  have  failed  to  do  so  altogether. 


INJURIES   TO   TIIK   PELVIC   FLOOR.  159 

A  suppository  of  niorph.  Kiilpli.  and  ext.  belladonnae,  each  a  fifth  of 
a  grain,  was  nsed  night  and  morning  to  relieve  the  pain,  M^hich  did 
not  subside  wholly  until  tlie  m-orning  of  the  fourtli  day.  She  took 
very  little  nonrishuicnt— nothing  solid  until  the  fifth  day.  On  the 
evening  of  the  fonrth  day  she  had  a  dose  of  pnlv.  glycyrrhizse 
comp.,  and  at  noon  on  the  fifth  day  an  enema ;  this  moved  the  how- 
els,  and  from  that  time  they  were  kept  regular  by  the  same  means. 
After  the  second  day  the  perineal  bandage  was  removed  altogether 
and  the  lint-dressing  continued.  On  the  fifth  day  after  the  bowels 
moved  there  was  a  slight  discharge  from  the  vagina  containing 
traces  of  pus.  She  was  then  ordered  a  vaginal  injection  of  sid- 
phate  of  zinc,  sixty  grains  to  a  quart  of  warm  water,  given  with 
the  fountain  syringe  at  low  pressure,  so  as  not  to  distend  the  vagina 
too  much.  This  was  continued  once  a  day  until  the  eighth  day,  and 
after  that  twice  a  day  for  another  week.  She  was  unable  to  urinate, 
and  hence  the  catheter  had  to  be  used  until  the  tenth  day  after  the 
operation.  This  gave  rise  to  a  slight  cystitis ;  it  was  treated  by  a 
teaspoonful  of  sweet  spirits  of  niter  in  a  small  glass  of  flaxseed-tea 
every  five  hours,  continued  for  three  days.  The  sutures  were  re- 
moved on  the  tenth  day,  and  union  appeared  to  be  complete.  She 
was  not  permitted  to  leave  the  bed  until  the  eighteenth  day.  The 
vaginal  douche  of  zinc  solution  was  continued  up  to  the  next  men- 
strual period,  and  then  discontinued.  After  the  flow  ceased,  the 
douching  was  resumed,  and  continued  for  two  weeks  longer. 

She  was  examined  two  months  after  the  operation,  and  the  re- 
sult was  found  to  be  perfectly  good. 

Laceration  of  the  Levator-ani  Muscle  and  Laceration  in  the  First 
Degree  in  the  Median  Line  of  the  Pelvic  Floor. — The  patient  was 
thirty-four  years  old,  and  had  three  children — the  eldest  ten  and  the 
youngest  three  years  of  age.  The  la^t  child  was  delivered  with  for- 
ceps, and  she  dates  her  trouble  from  that  time.  She  gave  the  symp- 
toms of  displacement  of  the  pelvic  organs  in  a  marked  degree. 
Standing  and  walking  caused  great  distress.  She  was  constipated, 
and  had  great  difficulty  in  evacuating  the  bowels.  She  felt  that  the 
rectum  had  lost  its  expelling  power,  and,  when  she  made  voluntary 
efforts  during  defecation,  the  vaginal  walls  protruded. 

The  laceration  in  the  median  line  was  not  more  than  half-way 
down  to  the  sphincter-ani  muscle,  but  the  parts  were  relaxed,  and 
both  vaginal  walls  prolapsed.  The  uterus  was  also  retroverted  and 
low  down.  There  was  complete  separation  of  the  transversus-peri- 
niei  muscle,  and  the  bulbo-cavernosus  muscle  was  either  lacerated 
or  else  overstretched,  so  that  it  was  functionally  imperfect.     The 


IGO  DISEASES   OF   WOMEN. 

posterior  half  of  the  pelvic  Hoor  was  displaced  downwani,  and  the 
levator-ani  niuscle  did  not  contract  on  beint^  stimulated.  The  touch 
also  showed  that  the  levator  had  ai)])arently  become  atrophied.  Rest 
in  the  recumbent  position  for  two  weeks,  and  support  of  the  pelvic 
floor  and  uterus  by  a  tampon  in  the  vagina  and  a  )>erineal  bandage, 
did  not  restore  the  tonicity  of  the  pelvic  floor  sufficiently  to  encour- 
age a  continuation  of  that  treatment.  It  was  now  evident  that  the 
levator  ani  could  not  be  restored.  I  then  decided  to  operate  with 
the  hope  of  restoring  the  bulbo-caveruosus  and  trans  versus- perinaei 
muscles  and  indirectly  uniting  them  to  the  sphincter  ani,  to  com- 
pensate, as  far  as  possible,  for  the  loss  of  the  levator. 

The  operation  was  the  same  as  that  performed  for  subcutaneous 
laceration  in  the  median  line,  excepting  tliat  all  the  tissues  were  re- 
moved down  to  the  sphincter  ani,  and  the  denudation  was  carried 
high  up  in  the  posterior  vaginal  walls  and  on  each  side.  Care  was 
taken  to  support  the  pelvic  floor  during  the  healing  process,  and  the 
nurse  protected  the  parts  with  counter-pressure  when  the  bowels 
moved.  Good  union  was  obtained,  and  at  the  end  of  a  month  it 
was  e^ddent  that  the  muscles  had  been  restored,  excepting  the  levator 
ani.  The  loss  of  this  muscle  was,  to  a  considerable  extent,  compen- 
sated for  by  the  restoration  of  the  other  muscles,  but  there  was  still 
sagging  of  the  posterior  part  of  the  pelvic  floor.  The  patient  was 
not  permitted  to  walk  or  stand  much  for  a  month,  and  the  retro- 
verted  uterus  was  kept  in  place  with  a  pessary.  She  was  greatly  re- 
lieved, but,  at  the  end  of  a  year,  she  was  still  unable  to  take  her  full 
share  of  active  exercise  without  supporting  the  ])arts  with  a  perineal 
bandage.  With  the  aid  of  this  support  her  usefulness  was  nearly 
restored,  but  she  was  not  cured  completely. 

Atrophy  and  Permanent  Paralysis  of  the  Muscles  of  the  Pelvic 
Floor. — Tlie  patient  was  forty-three  years  old  when  first  treated ; 
she  had  borne  two  children,  the  youngest  being  fifteen  years  old,  and 
had  had  a  large  number  of  miscarriages.  Her  first  labor  was  tedious 
and  instrumental,  but  she  made  a  fair  recovery.  When  first  seen 
there  was  a  general  sagging  of  the  pelvic  floor,  great  distention  of 
the  -snilva,  rectocele  and  cystocele,  and  prolapsus  of  the  uterus. 
There  had  been  a  very  slight  median  laceration  of  the  skin  and  rau- 
cous membrane,  and  evidently  complete  subcutaneous  laceration  of 
the  muscles  at  the  median  line.  At  that  time,  fourteen  years  ago,  I 
did  not  understand  the  nature  of  such  cases,  hence  I  followed  the 
authorities  and  treated  her  in  the  usual  way.  She  was  placed  in  bed 
and  the  pelvic  organs  kept  in  position,  and,  when  the  parts  had  ap- 
parently improved  in  nutrition  sufficiently  to  give  pros})ects  of  heal- 


INJURIES   TO   THE   PELVIC   FLOOR.  161 

\n(r,  the  usual  operati(.)n  was  pert'onned.  The  result  was  ajipareutly 
ali  that  could  be  desired  when  the  sutures  were  removed.  So  far  as 
the  shape  and  quantity  of  tissue  was  concerned,  the  perineal  body  was 
restored,  but  it  proved  to  be  functionally  useless.  As  soon  as  the 
patient  returned  to  her  usual  liabits  of  life  the  vaginal  walls  and 
uterus  began  to  descend  and  put  the  central  portion  of  the  floor 
upon  the  stretch,  which  caused  pain  in  the  scar  tissue,  so  that  she 
suifered  more  than  before  the  operation.  The  perineal  body  became 
thinned  by  distention  until  it  was  only  a  band  not  more  than  a  quar- 
ter of  an  inch  thick,  stretching  across  from  one  side  of  the  distended 
vulva  to  the  other.  Traction  upon  this  band,  of  scar  tissue  mostly, 
caused  by  the  protruding  vaginal  walls,  gave  such  acute  pain  upon 
standing  or  walking  that  it  was  necessary  to  incise  the  parts.  It  is 
needless  to  say  that  she  was  not  improved  by  the  treatment.  She 
passed  from  under  my  observation,  but  I  learned  that  about  a  year 
afterward  she  was  again  operated  upon  by  another  surgeon  with  no 
better  results.  Nearly  live  years  after  my  treatment  she  was  found 
among  the  incurables. 

Rigidity  of  the  Muscles  of  the  Pelvic  Floor  from  Inflammatory 
Sclerosis. — The  patient  was  a  delicate  blonde,  twenty-five  years  old. 
She  had  measles  at  twelve  years  of  age,  and  at  that  time  had  some 
inflammation  in  the  region  of  the  pelvic  floor  which  terminated  in  a 
discharge  of  pus  from  the  vagina.  Ever  since  then  she  has  had 
leucorrhoea.  At  puberty  the  menses  appeared,  and  have  continued 
normal.  She  was  married  six  months  before  I  first  saw  her.  Coitus 
was  found  to  be  impossible,  and  all  efforts  to  accomplish  it  caused 
her  great  pain.  An  examination  revealed  the  fact  that  she  had 
catarrh  of  the  cervix  and  a  vaginitis  such  as  occm's  in  the  strumous 
diathesis.  The  muscles  of  the  pelvic  floor  were  rigid  and  tender  to 
the  touch.  It  was  presumed  that,  when  the  inflammatory  disease  of 
the  cervix  and  vagina  was  relieved,  she  might  be  capable  of  fulfilling 
her  social  functions,  but  such  was  not  the  case.  Nitrous-oxide  gas 
was  used  to  produce  anaesthesia,  and,  with  a  Sims's  speculum,  the 
vulva  was  distended  sutiiciently  to  temporarily  paralyze  the  muscles. 
Seine  laceration  of  the  mucous  membrane  at  the  vulva  also  occurred, 
but  when  this  healed  the  rigidity  and  tenderness  of  the  pelvic  floor 
were  sufiiciently  relieved  to  permit  the  sexual  function.  About  two 
months  afterward  the  tenderness  and  rigidity  of  the  muscles  returned 
to  a  slight  extent,  but  were  promptly  and  permanently  relieved  by 
a  repetition  of  the  forcible  distention  with  the  speculum.  Several 
years  have  passed  since  this  treatment  was  employed,  but  there  has 
been  no  return  of  the  trouble. 

12 


CHAPTER  YIII. 

FISTULA    IN    ANO    AND   COCCYODVNIA. 

FISTULA  IN  ANO. 

Fistula  in  ano  in  women  differs  in  no  wise  from  the  same  affec- 
tion in  men,  so  far  as  its  pathology,  symptoms,  and  physical  signs  are 
concerned ;  and,  as  these  are  fully  described  in  treatises  on  surgery,  I 
shall  treat  of  them  here  only  incidentally.  But  the  treatment  of  tistula 
in  women  has  some  important  peculiarities  connected  with  it,  and  I 
propose,  therefore,  in  this  chapter  to  deal  with  the  subject  of  treat- 
ment alone,  giving  special  attention  to  those  points  of  difference  as 
I  have  observed  them  in  the  two  sexes. 

Having  had  several  very  unsatisfactory  results  in  treating  fistula 
in  ano  according  to  the  usual  methods  of  surgery,  I  determined  some 
years  ago  to  seek  other  means  better  adapted  to  the  relief  of  that 
affection  of  the  rectum.  The  history  of  my  own  failures,  and  those 
which  I  have  seen  after  treatment  by  other  surgeons,  may  be  the 
best  introduction  to  what  I  have  to  say  on  this  subject.  ]\Iy  fii*st 
case,  treated  in  hospital,  was  a  dissipated  woman,  who  did  nut  know 
her  age,  but  appeared  to  be  about  sixty.  She  had  a  very  severe 
purulent  vaginitis,  presumed  to  be  a  neglected  gonorrha'a,  and  also 
a  fistulous  opening  extending  from  the  side  of  the  perinanim,  about 
three  quarters  of  an  inch  from  the  mesial  line,  into  the  rectum  above 
the  sphincter  muscle.  AVhen  the  vaginitis  was  relieved,  I  treated 
the  fistula  by  laying  it  open  in  the  usual  way  and  placing  some  lint 
in  the  wound  so  as  to  make  it  heal  by  granulation  from  the  bottom ; 
in  this  I  was  disappointed.  The  divided  surfaces  slowly  healed  over, 
but  did  not  unite  by  intervening  granulations  or  by  new  tissue. 
The  result  was  that  the  divided  ends  of  the  sphincter  muscle  were 
never  united,  and  the  patient  lost  the  retaining  power  of  her  rectum. 
During  the  healing  process  applications  were  made  to  the  parts,  in 
the  hope  of  exciting  proliferations  to  fill  in  the  space,  but  without 
avail.  The  patient,  a  disgusting  creature  to  begin  with,  became 
much  worse  after  the  operation. 


FISTULA   IN   ANO   AND   COOOYODYNIA.  163 

While  I  was  thinking  of  some  way  to  restore  Lcr  sphincter,  she 
was  granted  leave  of  absence  from  the  hospital  one  afternoon,  and, 
promjitly  getting  drunk,  was  arrested  and  sent  to  jail  next  morning 
by  tlie  police  justice,  who  remembered  her  of  old.  What  her  sul> 
sequent  history  was  I  do  not  know,  but  I  do  know  that  I  felt  relieved 
when  I  heard  of  the  disposition  made  of  her  by  the  judge. 

The  next  case  of  fistula  occurred  in  private  practice ;  it  was  that 
of  a  young  lady  who  broke  down  from  over-taxation  and  dysmenor- 
rhoaa.  She  had  a  pelvic  abscess  and  finally  a  fistula,  which  I  was 
called  upon  to  treat  after  her  physician  had  partially  restored  her 
health.  The  external  opening  of  the  fistula  was  situated  in  the  an- 
terior and  lateral  portion  of  the  perinseum.  Owing  to  my  experience 
with  my  hospital  patient  I  was  unmlling  to  opei'ate  in  the  same 
way,  but  gladly  decided  to  employ  the  elastic  ligature,  strongly  rec- 
ommended at  that  time  in  the  treatment  of  fistula.  Accordingly,  I 
passed  the  ligature  through  the  canal,  and,  bringing  the  end  out 
through  the  anus,  tied  it  rather  tightly.  Considerable  pain,  which 
caused  my  patient  great  suffering,  followed,  and  lighted  up  many  of 
the  old  nervous  symptoms  from  which  she  had  just  recovered.  The 
ligature  cut  its  way  outward  rather  too  rapidly,  perhaps,  and  in  six 
days  all  the  tissues  were  divided  except  a  very  small  portion  of  the 
skin,  which  I  snipped  with  scissors.  The  parts  healed  over,  but  the 
ends  of  the  sphincter  muscle  did  not  unite.  In  fact,  the  result  was 
about  the  same  as  in  my  hospital  case.  For  a  long  time  the  retain- 
ing power  of  the  rectum  was  completely  lost.  Two  years  after  the 
operation  I  examined  her,  and  found  that  the  contraction  of  the  scar 
tissue  had  brought  the  ends  of  the  muscle  nearer  together,  but  still 
the  function  of  the  sphincter  was  imperfect.  The  patient  was  un- 
able to  retain  fluid  faeces  or  gas,  although  when  slightly  constipated 
she  experienced  very  little  trouble. 

Two  other  cases  have  come  under  my  observation,  in  which  the 
conditions  presented  were  very  much  like  those  described  in  my  own 
cases. 

The  first  one  was  a  lady,  thirty-two  years  of  age,  married  for  ten 
years,  and  sterile.  For  three  years  she  had  suffered  from  a  painful 
growth  at  the  meatus  urinarius  ;  this  gave  rise  to  so  great  tenderness 
as  to  prevent  coitus  and  to  cause  distress  during  micturition.  The 
tumor  was  removed  and  the  parts  healed  well  after  the  operation, 
but  still  she  had  symptoms  of  vaginismus  which  compelled  her  to 
return  for  further  treatment.  A  careful  examination  revealed  the 
following  condition  :  The  perinaeum  was  shorter  than  normal,  and 
was  drawn  upward  by  the  action  of  the  sphincter-vagin-ae  muscle 


lOi  DISEASES   OF    WOMEN. 

until  it  nearly  closed  the  introitus  va<^iniB.  The  rectum  appeared  tn 
be  also  drawn  forward,  bo  that  the  distance  from  tliu  po.steriur  wall 
of  the  rectum  to  the  meatus  uriuarius  wa.s  altogether  shorter  than  is 
usually  found.  A  scar  was  formed  on  the  right  margin  of  the  anus. 
The  function  of  the  sphincter  ani  was  imj)aired,  U})on  inquiry,  1 
learned  that  seven  years  before  she  had  been  operated  on  for  listula. 
and  had  never  since  had  complete  control  of  the  rectum. 

The  other  case  referred  to  so  closely  resembled  in  history  those 
just  given  that  it  need  not  be  related  in  full.  The  only  point  of 
diHerence  was  that  this  patient  sought  advice  regarding  her  want  of 
control  of  the  rectum.  It  will  be  observed  that  in  all  four  of  these 
cases  the  fistuloe  were  situated  either  upon  the  anterior  c»r  lateral 
margins  of  the  anus.  A  question  here  arises,  whether  the  operation 
for  listula  situated  more  toward  the  ]iosterior  margin  of  the  rectum 
would  terminate  iu  the  same  unfavorable  way.  This  1  can  not  an- 
swer, as  I  have  never  seen  a  case ;  I  can  not,  however,  see  an}-  reasoQ 
why  it  should  not  do  so.  I  am  not  disposed  to  believe  that  the  re- 
sults obtained  in  the  operation  for  tistula  in  ano  are  always  so  unfort- 
unate as  in  the  cases  recorded  here.  If  that  had  proved  to  be  the 
case,  the  attention  of  surgeons  would  have  been  given  to  the  subject 
long  ago. 

That  the  power  of  the  s})hiueter-ani  muscle  is  lost  in  a  large 
number  of  cases  aftei"  the  operation  is,  I  believe,  a  fact.  I  might  go 
further  than  this  and  say  that,  in  all  cases  in  which  the  listula  is  lo- 
cated completely  outside  of  the  muscle,  and  it  is  therefore  necessary 
to  divide  the  sphincter  in  operating,  there  is  great  danger  that  it  will 
not  be  fully  restored.  The  divided  muscle  retracts,  and  the  space 
between  its  ends  is  filled  in  very  slowly  with  new  tissue;  as  a  result, 
there  is  usually  a  large  amount  of  scar  tissue  necessary  to  connect 
the  two  ends.  This  must  impair  its  functions,  if  it  does  not  entirely 
destroy  it. 

In  a  healthy  subject  in  whom  the  termination  of  the  fist\da  does 
not  extend  far  outward,  and  the  induration  of  the  tissues  around  the 
canal  is  not  extensive,  the  healing  process  may  go  on  ra})idly,  thus 
coimecting  the  ends  of  the  muscle  by  means  of  intervening  new  tissue. 
Under  such  circumstances,  the  function  of  the  muscle  may  l)e  re- 
tained ;  on  the  other  hand,  if  the  fistula  extends  from  high  up  in  the 
rectum  to  a  point  some  distance  outside  of  the  nmscle,  the  operation 
is  almost  sure  to  be  a  failure.  Of  course,  the  greater  the  amount  of 
tissue  between  the  rectum  and  the  fistula,  the  farther  will  the  ends 
of  the  muscle  be  separated  by  retraction,  and  the  longer  will  the 
parts  be  in  healing.     In  such  cases  the  fimction  of  the  sphincter  is 


FISTULA   IN   ANO   AND   COCCYODYNIA.  165 

very  liable  to  be  impaired.  When  the  fistula  is  located  beneath  the 
mucous  menibraue  only,  then  a  j)erfect  result  can  always  be  obtained. 
Mr.  John  Gray  ("Lancet,"  December  11,  1S80)  states  that  operative 
treatment  should  be  deferred  until  the  walls  of  the  abscess,  as  well 
as  the  consequent  fistulous  tract,  have  assumed  a  condition  of  health 
and  a  disposition  to  take  on  a  healing  process.  This  is  certainly  a 
good  rale  in  surgery,  because  it  secures,  as  far  as  possible,  the  con- 
dition necessary  to  prevent  fecal  incontinence.  In  order  to  avoid 
such  unfavorable  results,  it  was  evidently  necessary  to  operate  with- 
out dividing  the  sphincter  muscle,  or,  if  that  were  impracticable,  to 
secure  union  of  the  divided  ends  of  the  muscle  with  the  least  possi- 
ble quantity  of  intervening  new  tissue. 

In  the  hope  of  curing  the  fistula  without  dividing  the  sphincter, 
the  following  method  was  adopted  :  An  incision  was  made  through 
the  skin  and  lower  part  of  the  sinus  large  enough  to  admit  two  lin- 
gers below  and  one  at  the  upper  end  of  the  wound.  The  edges  of 
the  wound  were  held  apart  with  retractors,  and  the  opening  in  the 
rectum  was  found  and  brought  into  view  by  passing  the  linger  into 
the  rectum  and  everting  the  rectal  wall  through  the  wound.  The 
edges  of  the  opening  in  the  rectal  wall  were  then  pared  with  the 
scissors,  and  two  or  more  catgut  sutures  were  introduced  and  tied. 
The  external  edges  of  the  wound  were  kept  apart  by  a  pledget  of 
carbolized  lint,  which  was  changed  every  day  until  the  wound  healed. 
The  idea  was  to  first  convert  a  complete  fistula  into  a  blind  external 
one,  and  then  finish  the  cure  by  compelling  the  external  sinus  to  heal 
from  below  outward.  To  prevent  any  strain  upon  the  sutures  by 
distention  of  the  rectum,  I  paralyzed  the  sphincter  by  overdistention, 
and  kept  the  bowels  free  by  saline  laxatives.  Of  two  cases  treated 
in  this  way  one  was  a  success  and  the  other  only  partially  so,  as 
the  opening  into  the  rectum  closed,  but  a  blind  external  fistula  re- 
mained. 

Regarding  this  method  of  treating  fi^stula,  I  can  only  say  that  the 
danger  of  losing  the  sphincter  muscle  is  avoided,  which  is  very  im- 
portant, hut  there  are  objections  to  it.  The  operation  is  dilficult  to 
perform — at  least  the  closing  of  the  opening  in  the  rectum  with  sut- 
ures is  not  easy — and,  then,  my  impression  is  that  it  will  fail  to  cure 
some  cases. 

AVhile  thinking  of  some  other  method  of  treatment  more  satis- 
factory than  that  given  above,  I  noticed  a  suggestion  in  the  "  Chicago 
Medical  Review,"  by  Dr.  Dudley,  to  lay  open  the  Ustula,  trim  oH 
the  indurated  tissues  along  its  track,  and  treat  as  a  lacerated  perinfeum, 
with  sutures.     It  occurred  to  me  that  this  method  was  deserving  of 


10)6 


DISEASES  OF   WOMEX. 


II  trial,  and  I  detorniined  to  ])iit  it  to  the  test  of  practice  as  soon  as  Ii 
could  get  an  opportunity.  It  was,  of  course,  impossible  to  tell  what 
the  results  would  be,  but  I  thought  that  it  promised  as  much  as  the 
meth«»ds  which  I  had  used.  Such  an  oj)portunity  presented  itself  to 
me,  and  the  result  will  be  seen  in  the  followinf!;  history: 

Fistula  in  Ano  successfully  treated  by  the  New  Method. — The  ]xi- 
tient  was  a  married  lady,  wIkj  had  antetlexion  of  the  uterus,  which 
caused  sterility.  On  two  occasions  she  had  dysentery,  which  left  a 
tender  condition  of  the  rectum  and  hfumorrhoids.  While  under 
treatment  for  the  flexion  of  the  uterus,  she  had  an  abscess  on  the 
right  side  of  the  anus,  which  terminated  in  the  formation  of  a  com- 
plete fistula.  The 
external  opening 
was  about  an  inch 
from  the  anus  on 
the  right  side,  and 
the  internal  open- 
ing was  immedi- 
ately above  the 
sphincter-ani  mus- 
cle. 

There  was  the 
usual  exudation 
around  the  fistu- 
lous tract,  but  it 
was  not  so  exten- 
sive as  in  many  of 
these  cases.  The 
rectum  having 
Iteen  thorougldy 
washed  out  with 
disinfectants,  after 
a  free  evacuation 
of  the  bowels,  a 
bivalve  rectal  spec- 
ulum was  intro- 
duced and  the  fis- 
tula laid  open.  The 
scar  tissue  was  care- 
fully dissected  out. 
and  special  care  was  taken  to  vivify  the  mucous  membrane  around 
the  upper  opening  of  the  fistula.     The  ends  of  the  sphincter  muscle 


I 


Fig.  89. — The  operation  for  lisluhi ;  the  trait  laiil  open  and  the 
sutures  in  place,     a,  anus ;  r,  outer  end  of  fistula. 


FISTULA   IN   ANO   AND   COOOYODYNIA.  1G7 

retracted,  so  that  it  was  necessary  to  remove  a  considerable  portion 
of  the  mucons  membrane  and  cellular  tissue  in  order  to  expose  the 
ends  of  the  muscle  in  the  edges  of  the  wound.  Fine  silk  sutures 
were  then  introduced  into  the  nmcous  membrane  of  the  rectum,  the 
lower  ones  being  made  to  include  the  sphincter-ani  muscle. 

Deep  sutures  were  then  introduced  from  the  outside  upward  in 
the  same  manner  as  in  the  operation  for  restoring  the  perinseum. 
Fig.  89  shows  the  sutures  in  place.  The  deep  sutures  were  tied  first, 
and  the  slight  traction  upon  them  drew  the  tissues  downward  and 
shortened  the  length  of  the  wound  very  much.  This  brought  the 
sutures  in  the  mucous  membrane  very  near  together.  I  should  have 
stated  that  before  the  fistula  was  laid  open  the  sphincter-ani  muscle 
was  stretched  until  paralyzed ;  this  prevented  any  tension  upon  the 
sutures  for  the  first  few  days. 

The  bowels  were  moved  daily,  and  after  each  evacuation  the  rec- 
tum was  washed  out  with  carbolized  water.  There  was  a  little  sup- 
puration in  the  track  of  one  deep  suture,  but  union  was  complete  in 
ten  days.  The  deep  sutures  were  removed  on  the  ninth  day,  and 
the  sutures  in  the  mucous  membrane  were  removed  at  the  end  of 
two  weeks. 

The  recovery  w^as  perfect,  the  function  of  the  sphincter  muscle 
being  fully  restored. 

COCCYODYNIA. 

This  affection  was  first  described  as  a  neuralgia  of  the  coccyx  by 
Dr.  ISTott  in  the  "  jSTorth  American  Medical  Journal,"  May,  1884, 
but  it  attracted  little  attention  until  1861,  when  Sir  James  Y.  Simp- 
son revived  the  subject  and  gave  it  the  name  which  it  now  bears. 

Pathology. — Pain  upon  moving  the  coccyx  and  contracting  the 
muscles  attached  to  it  is  the  chief  characteristic  of  this  disorder. 
The  morbid  conditions  found  are  variable.  Fracture  and  dislocation 
of  long  standing  and  caries  of  the  coccyx  have  been  discovered  in 
some  cases ;  in  others,  no  appreciable  lesions  can  be  detected.  It  is 
presumed  that,  in  the  absence  of  structural  changes  of  the  bone  and 
muscles,  the  pain  may  be  due  to  rheumatism  of  the  tendons  of  the 
muscles  or  neuralgia  of  the  nerves  distributed  to  them. 

Symptomatology. — There  is  little  or  no  suffering  while  the  pa- 
tient is  at  rest,  but  upon  rising,  sitting  down,  or  evacuating  the  bow- 
els, pain  over  the  coccyx  is  experienced.  Sitting  is  painful  in  some 
cases,  owing  to  pressure  upon  the  bone.  Any  sudden  movement  is 
attended  with  suffering.  Some  patients  are  unable  to  rise  from  a 
low  seat  without  assistance. 


108  DISEASES   UF   WOMEN. 

Physical  Signs. — Tenderness  upon  pressinc;  and  moving  tlie  cor- 
cyx  is   tlie  cliief  diagnostic  si<^n.     Painful  liu-niorriioids.  fissure  <>f 
the  anus,  and  spasm  of  the  adjacent  nuisclcs  caused  by  ascaricJes  in 
the  rectum,  may  be  mistaken  for  tliis  affection,  but  they  can  be  ex-  i 
chided  by  physical  examination. 

J*j'o</n(Ksis. — Some  cases  of  coccyodynia  are  slight,  and  wear  away 
in  time  without  special  treatment;  but,  though  the  disease  may  not ^ 
perceptibly  injure  the  general  health  of  the  patient,  it  is  often  of  such 
long  duration,  and  occasions. so  much  suffering  and  inconvenience, 
that  it  is  necessary  to  resort  to  surgical  means  for  relief. 

Cassation. — Women  who  have  borne  children  are  the  most  fre- 
quent, though  not  the  only,  sufferers  from  tlus  disorder.  Injuries 
sustained  in  parturition,  or  blows  upon  the  coccyx,  exposure  to  cold, 
and  diseases  of  the  ovaries  and  uterus,  are  its  chief  causes. 

Treatment. — The  surgical  inetliods  of  treatment  are  those  prac- 
ticed by  Prof.  Simpson  and  Dr.  Nott,  Neither  of  them  is  danger- 
ous, and  one  or  the  other  is  certain  to  give  satisfactory  results. 

By  Prof.  Simpson's  method  an  ordinary  tenotomy-knife  is  in- 
serted at  the  lowest  point  of  the  coccyx,  and  passed  flatwise  between 
the  skin  and  cellular  tissue  till  its  point  reaches  the  junction  of  the 
sacrum  and  coccyx.  Then  the  knife  is  turned  and  withdrawn,  mak- 
ing a  subcutaneous  incision  which  entirely  severs  the  muscles  over 
one  side  of  the  coccyx.  The  same  operation  is  repeated  on  the  other 
side.  No  haemorrhage  is  to  be  feared  in  subcutaneous  operations 
unless  some  large  vessel  should  be  cut. 

An  easier  operation,  and  one  more  likely  to  effect  a  cure,  is 
performed  by  exposing  the  coccyx  through  an  external  incision, 
raising  the  extremity  of  the  bone,  and  severing  the  muscles  with  a 
pair  of  scissors.  The  subcutaneous  operation,  always  diflicult,  is 
nearly  impossible  where  the  bone  is  covered  with  much  adipose 
tissue. 

Should  the  bone  itself  be  diseased,  section  of  the  muscles  would 
not  effect  a  cure.  In  such  cases  the  coccyx  must  be  laid  bare,  dis- 
articulated by  the  knife,  and  amputated,  according  to  the  method  of 
Dr.  Nott. 

The  complete  removal  of  the  coccyx  is  the  only  method  which 
has  proved  satisfactory  in  my  practice.  Nott's  method  of  ojjerating 
is  to  expose  the  coccyx,  detach  the  muscles,  and  then  take  it  off  from 
the  sacrum  with  "the  bone-forceps.  In  this  operation  there  is  danger 
of  injuring  the  sacrum,  and  causing  a  subsequent  necrosis.  I  there- 
fore prefer  to  disarticulate  with  the  knife  or  scissors,  cutting  through 
the  cartilage. 


FISTULA  IN   ANO   AND   OOCOYODYNIA.  169 

•    While  all  my  operations  have  been  finally  successful,  I  have 
several  times  seen  great  suffering  and  slow  healing  follow. 

The  subjoined  cases  will  illustrate  the  pain  and  suffering  which 
may  follow  the  operation, 

TLHISTKATIVE    CASES. 

Removal  of  the  Coccyx  and  Lower  Segment  of  the  Sacrum ;  Recov- 
ery.— A  married  lady,  twenty- four  years  of  age,  was  thrown  from  a 
carriage  and  injured  by  falling  upon  her  back  and  side,  bruising  the 
lower  end  of  the  spine,  and  having  what  was  supposed  to  be  a  fract- 
ure of  the  neck  of  the  femur.  After  recovering  from  the  imme- 
diate effect  of  the  accident,  she  suffered  from  severe  pain  in  the 
coccyx.  At  first  the  pain  in  that  region  was  almost  continuous,  and 
greatly  aggravated  by  locomotion.  For  about  six  months  from  the 
time  of  her  accident  she  was  tolerably  comfortable  while  resting,  but 
suffered  greatly  when  moving  around,  especially  upon  rising  from  a 
chair  or  sitting  down  or  turning  in  bed.  She  also  had  severe  at- 
tacks of  sick  headache  and  pains  in  the  back  of  the  neck. 

On  physical  exploration  it  was  found  that  the  coccyx  and  lowest 
segment  of  the  sacrum  projected  inward  at  nearly  right  angles  to 
the  axis  of  the  sacrum.  In  this  dislocation  the  coccyx  was  firmly 
fixed.  The  dislocation  and  the  tenderness  gave  rise  to  violent  jDain 
on  defecation. 

The  operation  consisted  in  removing  the  coccyx  and  the  lowest 
segment  of  the  sacrum.  A  free  incision  was  made  and  all  the  mus- 
cles and  attached  ligaments  were  separated,  and  then  the  part  to  be 
removed  was  carefully  disarticulated  without  any  injury  to  the  bone. 
The  operation  was  done  with  all  antiseptic  precautions,  all  hnsmor- 
rhage  was  controlled,  and  the  edges  of  the  wound  were  brought  to- 
gether with  sutures,  and  dressed  with  absorbent  cotton. 

On  recovering  from  the  anaesthetic  she  complained  of  the  most 
agonizing  pain  in  the  lower  half  of  the  back,  pelvis,  and  limbs. 
This  pain  continued  for  the  first  three  days,  and  was  only  partially 
controlled  by  large  hypodermics  of  Magendie's  solution,  ten  minims, 
every  two  to  four  hours. 

An  effort  was  made  to  relieve  the  pain  with  opium  given  by  the 
mouth,  but,  although  seven  grains  were  given  in  twelve  hours,  it 
was  necessary  to  repeat  the  hypodermics  to  give  her  relief.  During 
all  this  time  of  suffering  the  wound  appeared  to  be  healing,  there 
was  no  undue  infiannnation,  and  no  suppuration.  Five  days  after 
the  operation  the  pain  was  more  easily  controlled  by  the  morphine, 
I  and  then  the  sutures  were  removed,  and  the  pain  from  this  time  on- 


170  DISEASES   OF   WOMEN. 

ward  diminished  quite  rapidly.  At  this  time  the  wound  appeared 
to  be  e(nnj)letely  healed,  but  a  portion  of  the  cicatrix  broke  down, 
and  subsequently  healed  by  graimlation.  From  this  time  on  her 
progress  was  entirely  satisfactory,  the  pain  subsided  in  the  neighbor- 
hootl  of  the  wound  and  spinal  column,  and  she  was  entirely  relieved 
from  her  nick  iR'adaches. 

Removal  of  Coccyx ;  Extreme  Pain  after  Operation ;  Delayed  Heal- 
ing of  the  Wound ;  Final  Recovery. — This  ^vaa  a  married  lady  who 
had  one  child  about  eight  ycarc  old.  She  had  suffered  from  pelvic 
cellulitis  following  miscarriage,  so  that  her  health  wa.s  very  much 
impaired.  She  fell  down-stairs  and  injured  her  coccyx  about  two 
years  before  she  came  under  my  observation. 

She  recovered  completely  from  her  pelvic  cellulitis.  She  de- 
veloped all  the  symptoms  and  physical  signs  of  coccyodynia.  The 
operation  was  performed  in  the  usual  M-ay,  and  every  care  taken  to 
secure  a  good  result.  After  ligating  the  small  vessels,  which  bled 
rather  freely,  there  was  a  little  serous  oozing,  so,  l^efore  closing  the 
wound  with  sutures,  I  introduced  a  few  strands  of  catgut  for  drain- 
age, and  dressed  the  wound  with  borated  cotton. 

From  the  time  of  the  operation  slie  had  a  great  deal  of  pain  and 
tenderness  in  the  region  of  the  wound ;  this  pain  and  tenderness  in- 
creased until  it  was  necessary  to  give  anodynes  liberally  to  relieve 
them.  After  about  live  days  the  violent  pain  subsided,  but  the 
wound  was  still  exceedingly  sensitive ;  the  drainage-threads  were  re- 
moved about  the  second  day,  and  the  sutures  at  the  end  of  one  week. 
The  union  was  complete,  except  a  sinus  in  the  center  which  ex- 
tended downward  the  depth  of  the  original  wound.  This  promptly 
closed  up  after  a  few  more  weeks,  but  there  w^as  still  great  tender- 
ness remaining  there.  She  returned  to  her  home  thirty  days  after 
the  operation,  with  the  wound  apparently  healed  but  still  tender. 
She  was  free  from  her  occipital  headaches  and  from  most  of  her  dis- 
tressing symptoms. 

Some  time  after  her  return  home  the  wound  reopened,  and,  al- 
though every  care  was  taken  oi  the  case  by  the  physician  in  charge, 
it  was  nearly  six  months  before  it  healed  entirely.  Through  all  this 
time  she  was  free  from  the  suffering  which  she  had  before  the  opera- 
tion, but  the  wound  was  still  tender.  Since  then  she  has  been  per- 
fectly well. 


CHAPTER  IX. 


INFLAISIMATOEY    AFFECTIONS    OF    THE    UTERUS. 


ANATOMY  OF  THE   UTERUS. 

Befoke  taking  up  the  various  forms  of  endometritis,  a  few  words 
regarding  the  anatomy  and  physiology  of  the  uterus  will  aid  in  mak- 
ing clear  what  follows  with  reference  to  the  pathology  and  physical 
signs  of  this  variety  of  uterine  disease.  The  uterus  is  a  triangular 
body  with  its  apex  below  when  in  its  normal  position  in  the  pelvis. 
It  varies  in  size  in  different  persons,  and  is  somewhat  larger  in  those 
who  have  borne  children  than  in  virgins.  Its  entire  length  is  about 
three  inches ;  the  width  from  the  entrance  of  one  Fallopian  tube 
to  the  other,  that 
is,  the  base  of  the 
triangle,  is  about 
two  inches  ;  and  it 
is  about  one  inch 
in  thickness.  It  is 
divided  into  the 
fundus,  body,  and 
cervix,  the  cervix 
being  about  as  long 
as  the  body  and 
very  nearly  as 
thick.  The  cervix 
is  divided  into  the 
intravaginal  and 
the  supravaginal 
portions,  the  form- 
er being  that  part 
which  projects  into  the  vagina,  and  the  latter  that  which  extends 
from  above  the  vagina  to  the  body  of  the  uterus. 


Fig.  90. — Mold  of  uterine  cavity 
in  the  virgin  (Guyon). 


-  Mold  of  uter- 
ine cavity  in  the  multi- 
para (Guyon). 


172 


DISEASES   OF   WOMEN. 


i 


/^'•mV.-. 


•: .'  ,vV,'.V;v:rri',--  ; 

vV','''   1''.'  ■  '  V''?''  ■'  - 


'/"/.(ll'   -■'  .-."-fV-..,CxJ-i'?^':' 


dJU. 


Fig.  92. — Section  of  mucous  membrane  of 
uterus  from  near  the  fundus  (.Schiifer) : 
a,  epithelium  of  inner  surface  ;  h,  A, 
utricular  plands ;  c,  connective  tissue  ;  f/, 
muscular  tissue. 


The  walls  of  the  uterus  ;ire 
composed  of  three  distinct  ele- 
ments: the  outer  covering  being 
peritoneal ;  the  middle  coat,  un- 
striped  muscular  fiber ;  and  the 
internal,  mucous  membrane. 

The  peritona?um  covers  the 
uterus  only  partially,  but  the  nm- 
cous  membrane  lines  the  entire 
cavity  of  the  body  and  cervix,  and 
is  continuous  with  the  mucous 
membrane  of  the  vagina,  altliough 
differing  decidedly  in  structure. 
Reference  will  be  again  made  to 
the  relation  of  the  peritonanim  to 
the  uterus. 

The  cavity  of  the  uterus  and 
its  mucous  membrane,  which  are 
of  s^Decial  interest  in  this  connec- 
tion, are  divided  into  the  cervical 
canal  and  its  membrane  and  the 
cavity  of  the  body  and  its  mem- 
brane. The  cavity  of  the  body  is 
triangular  and  curvilinear,  M'hile 
the  canal  of  the  cervix  is  spindle- 
shaped.  Outlines  of  the  cavity  of 
the  canal  of  the  uteiiis  differ  in 
the  parous  and  iniparous  uterus 
(Figs.  90  and  91). 

The  constricted  portion  at  the 
junction  of  the  body  and  cervix  is 
the  OS  internum,  and  the  tcrnn'na- 
tion  of  the  canal  below  is  the  os 
externum.  Taking  the  cavity  of 
the  uterus  in  its  entirety  as  repre- 
senting a  tn'angle,  with  an  opening 
at  each  of  the  angles,  we  find  at 
the  upper  angles  the  openings  of 
the  Fallopian  tubes,  and  at  the 
lower  angle  the  os  externum. 

The  mucous  membrane  of  the 
cavity  of  the  body  is  smooth  and 


INFLAMMATORY   AFFECTIONS   OF   THE    UTERUS. 


173 


tliin,  the  membrane  proper  not  being  more  than  the  one  twelfth  of 
an  incli  in  thickness.  It  is  composed  of  an  epithelial  and  basement 
layer,  and  is  firmly  united  to  the  fibrous  tissue  of  the  middle  wall 
and  connective  tissues.  It  is  covered  with  a  single  layer  of  columnar 
cpitlu'liuni,  each  epithelial  cell  having  on  its  free  surface  a  l)undle 
of  cilia.  It  contains  a  number  of  glands  known  as  the  utricular 
glands.  In  a  section  of  the  mucons  membrane  these  glands  can  be 
seen  with  a  microscope  to  be  lined  with  ciliated,  columnar  epithe- 
lium, and  to  have  free  openings  on  the  surface  of  the  membrane. 
They  dip  oblique- 
ly downward,  and  .  f 
end  m  the  con- 
nective    and     fi-                C^^-^v.^■.^x■^.vCv^^s, 

I  brous  tissues  im-  V 

mediately  beneath 
the  membrane. 

Some  of  the 
glands  are  simple- 
others  are  bifur- 
cated at  their  low, 
er  ends  ;  some- 
times two  of  these 
glands  have  one 
opening  on  the 
free  surface. 

I  have  said 
that  the  glands 
dip  down  into  the 
muscular  fibers  of 
the  middle  coat ; 
others  describe 
the  muscular  fi- 
bers as  running 
up  between  the 
glands,  which 
amounts    to    the 

same  thing.  This  arrangement  of  the  utricular  glands  in  the  mucous 
membrane  and  the  muscular  wall  of  the  uterus,  with  the  intervening 
connective  tissue,  can  be  seen  by  referring  to  Fig.  92.  The  diflier- 
ences  in  the  infantile  and  senile  uterus  can  be  seen  bv  reference  to 
Figs,  m  and  94. 

The  mucous  membrane  lining  the  ceiwical  canal  is  arranged  in 


Fig.  93. — Transverse  section  through  middle  portion  of  the  corpus 
uteri  of  an  infant  7  months  old. 


174 


DISEASES   OF    WOMEN. 


an  entirely  different  manner  from  tliat  of  the  cavity  of  the  body. 
From  the  internal  to  the  external  08  there  are  sulci  which  divide  the 


r^:\=! 


Fig.  94. — Transverse  section  through  the  middle  portion  of  the  corpus  uteri  of  a  woman 

aged  83. 


membrane  into  four  divisions  or  cohimns.  The  niemlirane  between 
these  sulci  is  arranged  in  oblique  folds  or  ridges,  the  whole  making 
up  that  rugous  appearance  to  which  the  name  arho?'-vito3  has  been 
given.  Fig.  95  shows  this  peculiar  arrangement  of  the  membrane. 
This  membrane  is  covered  throughout  with  ciliated  epithelium.  The 
glands  of  the  cervix,  known  as  the  glands  of  Naboth,  are  of  the 
racemose  type ;  they  open  on  the  free  surface,  dip  down,  and  divide 
into  numerous  branches,  which  extend  deep  into  the  connective  tis- 
sues. Their  openings  are  found  on  the  surface  of  the  mucous  mem- 
brane, both  in  the  elevations  and  depressions. 

The  point  at  which  the  mucous  membrane  of  the  cervical  canal 
unites  with  the  membrane  which  covers  the  vaginal  portion  of  the 
cervix  is  the  os  uteri  externum,  and  the  structure  and  arrangement 
of  the  membrane  differ  on  the  two  sides  of  this  dividing  hue.  That 
within  the  canal  is  as  I  have  described  it,  and  that  which  covers  the 
cervix  outside  of  the  os  internum  contains  none  of  the  glands  of 
Naboth,  and  has  all  the  general  characteristics  of  the  mucous  mem- 


INFLAMMATORY   AFFECTIONS  OF  THE  UTERUS. 


175 


l)r;ine  of  the  vagina.     It  consists  of  vascular  papillae  covered  with 


many  layers  of  squamous  epithelium 
pens,  the  Nabothian  glands  are 
found  upon  the  vaginal  sur- 
face of  the  cervix,  it  is  evi- 
dence that  they  have  either 
been  developed  there  or  else 
there  is  eversion  of  the  mu- 
cous moral )]-ane  of  the  cervical 
canal,  and  the  latter,  I  believe, 
is  the  true  explanation  of  their 
presence  in  most  cases. 

The  middle  or  muscular 
wall  of  the  uterus  is  composed 
of  non-striped  muscular  fibers 
which  appear  to  be  rudiment- 
ary in  the  unimpregnated 
uterus.  This  middle  coat  is 
divided  into  three  layers :  a 
thin  subperitoneal  one  which 
is  continued  outward  in  the 
location  of  the  uterus,  a  mid- 
dle layer,  and  an  inner  con- 
centrated and  very  abundant 
layer  which  surrounds  the  Fal- 
lopian tubes,  OS  externum,  and 
OS  internum  ;  the  inner  portion 
of  this  layer  is  less  dense  than 
the  rest  of  it,  and  there  is  more 
connective  tissue  intermingled 
with  the  fibro  -  muscular  tis- 
sues. It  is  into  this  layer  that 
the  uterine  and  Xabothian 
glands  extend. 


When,  as  occasionally  hap- 


Fig.  95. — The  oblique  ramifications  of  one  of  the 
median  columns  in  the  cervical  canal  of  a 
virgin,  called  the  arbor-vitte  (9  diameters). 


FUNCTIONS    OF   THE    UTERUS. 


The  function  of  the  uterus  which  is  of  most  interest  to  the  gyne- 
cologist is  that  of  menstruation,  which  has  been  discussed  in  the 
third  chapter,  to  which  the  reader  is  referred.  It  will  be  spoken 
of  again  when  treating  of  corporeal  endometritis. 

The  function  of  the  cervix  in  relation  to  gestation  and  parturition 


176  DISEASES  OF   WOMEN. 

need  not  be  discussed  here ;  a  few  words,  liowever,  may  be  appro- 
priate in  rei^ard  to  the  relation  of  tlie  cervix  to  impregnation. 

There  are  two  j)rincipal  theoiies  in  reference  to  the  function  of 
the  cervix  uteri  in  the  transmission  of  the  fecundating  element  to 
the  body  of  the  nterus.  The  one  is  tliat  the  cervix  dilates,  and 
that  the  secretion  of  the  glands  of  ^'aboth  tills  the  canal  and  forms  a 
medium  through  which  the  spermatozoa  make  their  way  upward 
by  their  own  nugratiug  power.  This  appears  rational  from  the  fact 
that  the  secretion  of  the  Xabothian  glands  is,  in  its  physical  proper- 
ties, similar  to  the  seminal  fluid.  The  other  theory  is,  that  the  cer- 
vix expands,  extends,  contracts  and  retracts,  producing  an  action 
of  suction,  whereby  the  spermatozoa  are  carried  up  into  the  uterus. 
Whether  either  or  both  of  these  theories  is  correct,  there  is  no  doubt 
that  the  glands  of  Nal)Oth  secrete  a  fluid  that  is  concerned  in  the 
great  function  of  reproduction,  and  that  derangement  of  this  func- 
tion tends  to  the  development  of  cervical  endometritis,  and  that  they 
are  subject  to  important  pathological  changes  in  that  affection. 


METRITIS. 

There  are  sev^eral  varieties  of  uictritis.  Two  of  these  are  desig- 
nated by  the  character  of  the  inflammation,  acute  and  chronic ;  two 
are  classed  according  to  the  location  of  the  disease,  cervical  and  cor- 
poreal endometritis ;  and  there  are  at  least  three,  which  are  named 
in  part  from  the  causes  which  give  rise  to  them,  puerperal,  gonor- 
rhoeal,  and  exanthematous. 

To  define  these,  it  may  be  said  that  exanthematous  metritis  occurs 
in  the  course  of  some  of  the  eruptive  fevers,  and  usually  subsides 
after  recover}^  from  the  constitutional  disease  which  caused  it.  It 
is  an  acute  affection,  and  always  tends  to  recovery,  but  the  uterus 
may  be  damaged  by  the  disease.  When  it  occurs  in  the  young,  as  it 
often  does,  the  further  development  and  growth  of  the  uterus  may 
be  arrested  by  it.  This  is,  I  am  sure,  the  cause  of  many  cases  of 
imperfect  development  of  the  uterus.  The  acute  disease  may  sub- 
side, to  be  followed  by  a  chronic  metritis. 

The  puerperal  metritis  is  of  most  interest  to  the  obstetrician,  as 
it  occurs  in  connection  with  parturition.  It  has  a  traumatic  or  sej> 
tic  origin,  and  usually  involves  the  entire  uterus,  so  that  changes  of 
structure  are  found  in  the  mucous  and  muscular  coats  of  the  organ. 
Tliis  also  (when  it  terminates  in  recovery)  tends  to  chronic  inflam- 
mation of  the  mucous  membrane.  The  process  of  involution  is  ar- 
rested by  this  inflammation,  and  when  the  tissues  are  changed  by 


INFLAMMATORY   AFFECTIONS  OF  THE   UTERUS.  177 

iiiflaniinatory  action  the  uterus  is  not  only  larger  than  it  should  l)e 
hilt  is  changed  in  structure.  This  will  be  referred  to  again  under 
the  head  of  subinvolution. 

Endometritis  due  to  gonorrhoeal  virus  will  also  claim  a  separate 
notice,  and  with  these  few  observations  I  shall  for  the  present  dis- 
miss all  the  varieties  except  acute  and  chronic  endometritis,  which 
will  be  discussed  in  this  chapter. 

Acute  Endometritis. — Acute  endometritis  is  exceedingly  rare  if 
puerperal,  gonorrhoeal,  and  septic  inflammations  are  excluded.  I  am 
aware  that  acute  cervical  or  corporeal  endometritis  is  described  in 
books,  and  Thomas  claims  that  the  affection  occurs  frequently.  My 
own  observations  lead  me  to  the  conclusion  that  the  acute  metritis 
does  not  progress  beyond  the  stage  of  acute  congestion,  and  fre- 
quently passes  off  without  causing  the  slightest  permanent  change  of 
structure.  Occasionally  the  acute  stage  subsides,  and  a  chronic  or 
subacute  endometritis  follows.  When  one  follows  the  other  in  this 
way  they  stand  to  each  other  in  the  relation  of  cause  and  effect.  The 
disease  may  affect  the  cervix  or  the  body  or  both  at  the  same  time. 

Acute  cervical  endometritis  is  more  properly  an  acute  congestion, 
which  does  not  cause  any  very  marked  disturbance  either  of  the 
pelvic  organs  oi*  the  general  system.  The  symptoms  are  not  pro- 
nounced. Pelvic  tenesmus  of  a  slight  nature,  a  sense  of  aching 
in  the  pelvic  region,  with  or  without  backache,  is  the  evidence  ob- 
tained at  first,  and  then  leucorrhoea  soon  follows.  This  discharge  is 
usually  catarrhal  and  non-purulent.  In  some  cases  there  is  also  a 
vaginitis  and  a  vaginal  leucorrhoea  which  contains  some  pus-cells,  but 
when  there  is  a  free  purulent  discharge  there  is  room  for  a  suspicion 
that  the  cause  may  be  specific. 

This  form  of  cervical  endometritis  frequently  ends  in  recovery, 
but  may  become  chronic.  All  else  that  needs  to  be  said  on  this  sub- 
ject will  be  given  in  the  consideration  of  corporeal  endometritis. 

Acute  Corporeal  Endometritis. — While  I  have  stated  that  acute 
corporeal  endometritis  may  occur  alone,  I  have  always  found  it  ac- 
companied by  more  or  less  cervical  endometritis. 

The  pathology  of  acute  non-specific  endometritis  I  consider  to 
be  a  hyperremia,  with  such  derangement  of  function  as  may  come 
from  it.  This  congestion  may  lead  to  swelling  of  the  mucous  mem- 
brane, destruction  of  its  epithelium  to  some  extent,  and  the  forma- 
tion of  pus,  but  these  changes  are  not  so  marked  as  they  are  in  me- 
tritis due  to  specific  causes  There  is  derangement  of  the  menstrual 
function  ;  the  flow  may  be  retarded,  anticipated,  profuse,  or  scanty. 

A  free  menstruation  is  usually  very  beneficial.  Symptoms  often 
13 


178  DISEASES   OF   WOMEN. 

subside  as  soon  as  a  free  flow  is  establishtd,  and  if  this  flow  con- 
tinues the  usual  time  or  longer  the  patient  promptly  recovers.  Free 
menstruation  luis  always  a[)peared  to  me  to  be  a  natural  means  of 
relief  in  this  affection. 

The  symptoms  and  physical  signs  of  general  acute  endometritis 
are  similar  to  those  found  in  the  chronic  form  of  the  affection,  and 
to  save  repetition  these  points  will  be  taken  up  Under  the  head  of 
chronic  endometritis. 

Prognosis. — This  is  favorable.  The  great  majority  of  cases  re- 
cover, and  the  worst  tliat  may  happen  is  that  the  disease  may  linger 
and  assume  the  chronic  form. 

Causation. — The  causes  wliich  give  rise  to  ordinary  inflammation 
of  mucous  membranes  generally  will  produce  acute  endometritis, 
especially  if  operative  at  f»r  near  the  menstrual  period.  Extreme 
sexual  excitation  or  over-indulgence,  exposure  to  cold,  over-fatigue, 
and  injuries  from  careless  examinations  with  the  touch  or  instru- 
ments, are  fair  examples. 

Treatment. — Complete  rest  is  the  first  and  most  important  ele- 
ment in  the  management.  To  quiet  the  nervous  system,  full  doses 
of  bromide  of  sodium  should  be  given.  This  may  also  relieve  pain. 
Should,  the  suffering  still  persist,  opium  should  be  used,  but  not  if  it 
can  be  avoided  with  justice  to  the  sufferer. 

Hot  applications  should  be  made  over  the  hypogastrium.  Lin- 
seed-meal poultices,  covered  M-itli  oil-silk,  should  be  preferred,  but  if 
the  patient  complains  of  the  weight  flannels  wrung  out  of  hot  water 
may  be  used  in  the  same  manner.  The  hot-water  douche  should  be 
used  twice  or  three  times  a  day  if  it  gives  relief.  The  bowels  should 
be  kept  free  with  saline  laxatives ;  should  these  cause  flatulence  and 
pain,  a  laxative  pill  of  colocynth  or  rhubarb  and  belladonna  will 
answer  better. 

This  simple  treatment  is  generally  sufficient.  More  heroic  meas- 
ures are  often  resorted  to,  but  usually  with  the  result  of  prolonging 
the  disease. 

Chronic  Endometritis. — r)ne  would  naturally  suppose  that  in  en- 
dometritis the  inflammatory  process,  when  once  begun  at  any  part 
of  the  mucous  membrane,  would  extend  to  the  whole  endometrium, 
but  such  is  not  the  case.  Clinical  observations  show  that  cervical 
endometritis  frequently  occurs  without  corporeal.  They  occur  to- 
gether also,  but  cervical  endometritis  occurs  most  frequently.  This 
law  in  the  pathology  of  uterine  disease,  which  appears  peculiar,  is 
explained  possibly  by  the  fact  that  the  mucous  membrane  in  its  ana- 
tomical structure,  and  more  especially  in  its  function,  differs  very 


INFLAMMATORY    AFFECTIONS   OF   THE    UTERUS.  179 

widely  in  the  body  and  cervix  uteri.  Ceri-ain  it  is  that  the  pathology 
and  syniptouiatology,  as  well  as  the  physical  signs,  show  that  corporeal 
and  cervical  endometritis  are  two  very  distinct  affections,  demand- 
ing different  consideration  and  treatment.  At  the  same  time  I  nmst 
admit  that  they  have  many  features  in  common,  and  that  they  also 
occur  together  occasionally,  hence  I  shall  give  some  general  remarks 
which  will  apply  to  both. 

There  has  been  much  discussion  regarding  the  pathology  of  en- 
dometritis, both  cervical  and  corporeal.  Much  of  this  difference  of 
opinion  I  think  arises  from  the  use  of  the  terms.  Some  claim  that 
the  only  lesion  in  this  affection  is  congestion,  othei-s  claim  that 
there  is  true  inflammation ;  the  difference  apparently  arising  from 
the  fact  that  one  defines  inflammation  as  one  thing,  while  another 
believes  it  to  be  something  else.  If  endometritis,  as  we  usually 
see  it  in  practice,  is  compared  with  the  process  of  acute  inflamma- 
tion in  other  mucous  membranes  when  it  runs  its  entire  course, 
then  it  will  be  found  that  endometritis  is  exceptional.  It  is  known 
that  in  ordinary  inflammation  of  the  mucous  membranes  there  is 
tirst  congestion,  then  hypersecretion,  then  suppuration  or  purulent 
secretion,  occasionally  ulceration,  and  rarely,  if  ever,  except  in  spe- 
cific inflammation,  an  exudation  of  plastic  lymph ;  then  recovery 
follows.  The  damage  done  to  the  membranes  depends  upon  whether 
the  process  enlls  in  suppuration,  ulceration,  or  exudation.  If  this  is 
taken  as  the  typical  result  of  inflammation  of  mucous  membranes, 
then  it  is  a  fact  that  inflammation  of  the  mucous  membrane  of  the 
uterus  is  extremely  rare ;  but  the  fact  is,  that  the  process  of  inflam- 
mation in  mucous  membranes  begins  in  some  cases  and  progresses 
only  to  congestion  and  hypersecretion,  and  if  these  are  long  continued 
certain  changes  in  the  mucous  glands,  epithelium,  and  cellular  tissue 
take  place,  but  suppuration  or  ulceration  does  not  occur  as  a  rule  in 
endometritis. 

The  inflammatory  process  does  not  begin,  nm  through  all  its 
stages,  and  then  end,  but  it  begins  and  progresses  to  a  given  stage, 
and  is  continuous  instead  of  ending  at  a  definite  time. 

Cervical  EEdometritis.  —  Pailiology.  —  In  cervical  endometritis, 
which  is  now  usually  called  uterine  catarrh,  there  is  very  decided 
congestion  and  hypersecretion  of  the  glands  of  the  cervix.  This 
secretion  differs  very  little  in  its  physical  properties  from  that  which 
is  normal,  except  that  it  is  excessive  in  quantity.  If  this  congestion 
is  long  continued,  the  exfoliation  of  epithelium  progresses  faster  than 
its  replacement  by  the  development  of  new  cells,  so  that  the  membrane 
18  covered  \vith  young  epithelium  which  gives  it  a  reddish  color. 


180  DISEASES  OF   WOMEN. 

Tliis  disturbance  of  the  balance  batween  the  process  of  exfoliation 
and  reproduction  not  only  involves  the  mucous  membrane  of  the 
canal,  but  extends  outward  from  the  os  externum  about  half  the 
thickness  of  the  walls  of  the  cervix.  This  <^ives  rise  to  the  c<jn- 
ditions  which  were  described  by  the  older  writers  as  ulceration  of 
the  cervix  uteri. 

As  the  process  advances  the  mucous  membrane  becomes  thick- 
ened by  proliferation  of  the  areolar  tissue  and  by  distention  of  the 
blood-vessels,  so  that  it  becomes  too  large  for  the  surface  which 
it  covers;  this  throws  it  into  the  fine  inigosities  or  wrinkles  which 
give  the  surface  a  granular  or  jmpillous  appearance.  These  ])ro- 
jecting  points  were  supposed  bv  the  older  patliologists  to  be  an 
enlargement  of  the  papillae  of  the  nmcous  membrane,  but  it  is 
now  known  that  they  are  new  formations  due  to  areolar  hyper- 
plasia. It  is  supposed,  also,  that  the  glands  undergo  some  patho- 
logical change  other  than  mere  congestion,  but  probably  the  only 
change  is  a  congestion  and  modification  of  the  epithelium  which 
lines  them. 

It  is  claimed  by  some  that  new  glands  are  developed  upon  the 
outer  surface  of  the  cervix  around  the  os  externum ;  I  am  inclined 
to  think,  however,  that  the  glands  which  are  seen  outside  of  the  os 
externum  in  cervical  endometritis  appear  there  because  of  the  thick- 
ening of  the  mucous  membrane  which  causes  a  procidentia  or  pro- 
laj^sus  of  this  membrane. 

It  is  difficult  to  believe  that  the  inflammatory  process  could  lead 
to  the  development  of  new  anatomical  stinictures  of  a  normal  char- 
acter, but  there  is  strong  evidence  to  show  that  this  occurs  in  the 
mucous  membrane  of  the  cervix  uteri.  Sometimes  the  irregularity 
of  surface  due  to  hyperplasia  is  very  marked,  especially  in  cases 
where  there  is  laceration  of  the  cervix.  This  condition  has  been 
called  '•  granular  de^reneration  " — a  good  enouirh  name,  if  it  is  re- 
membered  that  it  is  produced  by  a  throwing  up  of  the  membrane 
into  folds  or  ])rojections  by  an  enlargement  and  thickening  due  tt) 
hyperplasia,  and  that  it  is  not  a  degeneration  in  fact. 

In  some  cases,  especially  those  that  have  been  treated  with  caus- 
tics, the  mouths  of  the  Nabothian  glands  become  closed  and  the 
glands  become  distended  by  their  secretion,  and  form  cyst-like  bodies 
deep  in  the  membrane.  These  are  usually  seen  at  the  surface  as 
whitish,  ])early-looking  points,  which  contrast  with  the  dcej>red  color 
of  the  mucous  membrane  around  them.  To  the  touch  they  feel  like 
shot,  imbedded  in  the  membrane ;  these  have  long  been  known  as 
the  "ovulfe  Nabothi "- -more  recently  this  condition  has  been  called 


INFLAMMATORY   AFFECTIONS   OF  THE   UTERUS.  181 

"  cystic  degeneration  of  the  cervix  "  (Fig.  9G).  Sometimes  one  or 
more  of  them  become  very  large,  and  by  pressure  cause  alisor])tion 
of  the  middle  wall  of  the  uterus  around  them. 

The  hypenemia  sometimes  extends  to  the  middle  coat  of  the  cer- 


Fig.  96. — Section  through  the   mucous   membrane  of  the  vaginal  portion  of  the  cervix 
showing  cystic  degeneration. 

vix,  and  then  for  a  time  the  tissues  are  softened  and  (pdematous. 
With  this  condition  there  is  usually  free  leucorrhoea  and  menor- 
rhagia,  especially  when  the  body  of  the  uterus  is  affected.  Occasion- 
ally, though  rarely,  the  menstrual  function  is  suspended  or  dimin- 
ished. In  some  cases  of  long  standing,  especially  when  there  is 
laceration  of  the  cervix,  the  areolar  hyperplasia  extends  to  all  the 
tissues  ^f  the  cervix,  giving  rise  to  that  iudm'ation  known  as  scle- 
rDsis. 


182 


DISEASES   OF    WoMliIN. 


These  are  the  principal  pathological  conditions  observed  in  the 
oi'diiKirv  forms  of  cervical  endoiucti'itis.     Occasioiuillv  the  di.scharp- 


Fig.  98.  —  Hypertrophy 
of  body  of  uterus  fol- 
lowing corporeal  endo- 
metritis (Winckel). 


Fig.  99. — General  enlaip- 
ment  of  uterus,  contrast  in;; 
with  the  two  preceding  fi;;- 
ures  (Winckel). 


Fig.  97.  —  Thickening  and 
elongation  of  the  cervix,  as 
a  result  ofcervical  endome- 
tritis (Winckel). 


may  be  miico  -  purulent,  at  times  it  is 
sero-nmco-purulent ;  but  this  occurs  only 
in  extreme  cases,  and  usually  is  due  to 
some  specific  cause,  and  hence  need  not  be  considered  in  this  con- 
nection. 

The  ordinary  form  of  cervical  endometritis,  described  above, 
occurs  in  jjarous  and  imparous  alike.  There  is  another  form  of  cer- 
vical endometritis  which  occurs  only  in  the  imparous,  and  has  some 
peculiar  characteristics  which  should  be  noticed  here.  In  these  cases 
the  changes  in  the  vessels  already  noted  may  or  may  not  be  present; 
usually  they  are  not.  The  discharge  from  the  cervical  can<al  is  not 
usually  profuse,  but  it  is  peculiar  in  character.  In  ]>la('e  of  the  clear, 
translucent  secretion  we  find  a  very  thick  and  exceedingly  tenacious 
material  of  the  consistency  of  thick  glue,  and  of  a  darkish  color  not 
unlike  ])neumonic  sputum,  though  more  solid  and  dense,  and  not  usu- 
ally so  bright-red  in  color.     Associated  with  this  peculiar  dischaige 


INFLAMMATORY   AFFECTIONS   OF    THE    UTERUS.  183 

there  are  usually  luarkecl  tenderness  and  djsuienorrlKea,  whicli  are 
not  accounted  for  by  any  other  condition  of  the  uterus  than  the  state 
of  the  cervical  mucous  membrane.  I  am  inclined  to  think  that  this 
form  of  cervical  disease  is  due  to  some  malformation  or  arrest  of  de- 
velopment of  the  glands  of  the  mucous  membrane.  I  have  been  led 
to  believe  this  because  it  occurs  in  those  in  whom  the  uterus  is  im- 
perfectl}^  developed  generally,  and  also  the  same  peculiar  secretion  is 
observed  in  some  women  after  the  menopause,  when  the  uterus  and 
its  mucous  membrane  have  undergone  tinal  involution. 

In  other  cases  of  this  class  the  mucous  membrane  of  the  cervix 
becomes  prola])sed,  causing  dilatation  and  inversion  of  the  lips  of 
the  external  os,  so  that  the  cervix  appears  as  if  it  had  sustained 
superficial,  bilateral  laceration.  In  such  cases  the  appearance  is  such 
as  to  lead  to  the  belief  that  the  patient  has  borne  children,  or  had  a 
miscarriage  ;  but  I  have  found  it  associated  with  unruptured  hymen, 
showing  that  it  could  not  have  come  from  injuries  during  parturition. 

Dr.  Emmet  describes  cases  of  laceration  that  he  has  seen  follow- 
ing criminal  abortion  in  those  who  have  not  borne  children.  In  the 
cases  to  which  I  refer  the  anatomical  appearances  are  the  same  as  he 
describes,  but  I  am  satisfied  that  in  those  that  have  come  under  my 
observation  the  laceration  was  apparent,  not  real.  As  soon  as  the 
membrane  is  reduced  to  its  normal  dimensions  by  exsection  of  a 
portion  of  it,  and  relief  of  the  inflammation  by  treatment  is  accom- 
plished, the  external  os  contracts,  and  the  cervix  resumes  its  original 
virgin  form,  showing  that  no  iujury  to  the  muscular  coats  of  the 
utenis  has  ever  occurred. 

Symptomatology.  —  Cervical  •  endometritis  does  not  necessarily 
give  rise  to  marked  constitutional  disturbance ;  when  it  does  so  the 
symptoms  usually  appear  in  the  form  of  general  debility,  especially 
of  the  nervous  system.  The  patient  may  become  easily  fatigued 
and  somewhat  changed  in  disposition,  and  less  inclined  to  mental 
activity.  Sometimes  there  is  considerable  mental  disturbance,  but 
nmch  of  all  this  is  usually  due  to  the  fact  that  the  patient  is  annoyed 
by  the  presence  of  a  more  or  less  profuse  leucorrhosa,  which  gives 
her  discomfort,  and  leads  her  to  suppose  that  she  is  suffering  from 
a  serious  affection.  The  constitutional  effects  of  this  local  affection 
depend  very  much  upon  the  sensitiveness  of  the  patient. 

The  menstnial  function  is  not  necessarily  affected.  In  cases  of 
long  standing  there  may  be  irregular  menstruation,  and  the  flow  may 
be  inclined  to  diminish,  but  this  is  not  the  rule. 

The  character  of  the  leucorrlioeal  discharge  is  diagnostic.  It  is 
dense,  thick,  opaque,  and  tenacious,  while  the  vaginal  leucorrhoea  is 


184  DISEASES   OF    WOMEN. 

serous,  non-tenacious,  and  usually  purulent.  If  the  disease  is  long 
c'oiitiinu'd  hackat'be  comes  on,  the  pn'ni  bfiiif^  located  in  the  sacral 
ivgiou,  which  distinguishes  it  from  the  lumbar  pain  characteristic  of 
general  delnlity  and  some  of  the  acute  diseases.  Theru  is  often, 
also,  some  pelvic  tenesmus.  All  these  symptonjs  are  usually  very 
much  aggravated  by  muscular  exercise;  the  sym])toms  alone,  how- 
ever, are  not  sufficient  to  enable  one  to  make  a  diagnosis.  All  that 
can  be  learned  from  them  is  sim})ly  rhat  there  is  some  uterine  affec- 
tion which,  if  it  does  not  yield  i)romptly  to  constitutional  treatment, 
demands  further  investigation  in  order  to  settle  definitely  its  char- 
acter. 

Physical  Signs. — These,  as  obtained  by  the  touch,  are  usually 
rather  unsatisfactory.  Upon  making  pressure  upon  the  cervix  there 
is  sometimes  tenderness,  but  not  always:  in  some  cases  a  roughened 
condition  of  the  nmcous  membrane  around  the  os  externum  can  be 
detected  by  the  touch.  Not  infrequently  there  is  a  little  relaxation 
of  the  vagina,  and  the  uterus  rests  lower  in  the  pelvis. 

Speculum  examination  affords  the  best  means  of  ascertaining  the 
lesions.  We  can  usually  see  enough  of  the  mucous  membrane  within 
the  OS  externum  to  determine  the  presence  of  the  inflammati(^n. 
This  is  rendered  more  positive  when  the  redness  and  ei'osiiju  of  the 
membrane  extend  outward  upon  the  vaginal  surface  of  the  cervix, 
and  also  when  there  is  eversion  of  the  membrane.  There  is  usually 
a  free  leucorrhoeal  discharge  from  the  cervical  canal.  Sometimes  tliis 
hypersecretion  is  the  only  evidence  of  the  disease  present.  Passing 
the  sound  into  the  cer^^cal  canal  shows  that  it  is  more  sensitive  than 
in  health,  and  the  membrane  bleeds  more  easily  on  touch  than 
it  should.  It  will  be  seen  that  the  physical  signs,  as  well  as  the 
symptoms,  are  not  by  any  means  marked  in  cervical  endometritis, 
yet  they  are  sufficient  for  diagnostic  purposes.  Whenever  the  con- 
stitutional disturbance  and  the  local  symptoms  are  severe,  it  may  at 
least  be  suspected  that  the  mcml)rane  of  the  cavity  of  the  body  of 
the  utenis  is  also  involved.  This  will  be  more  fully  discussed  under 
the  head  of  corporeal  endometritis. 

In  the  form  of  cervical  endometritis  referred  to,  in  which  the 
secretion  of  the  glands  is  opaque,  dark  in  color,  and  exceedingly  te- 
nacious, the  discharge  is  not  at  all  times  very  jjrofuse,  but  enough 
can  be  obtained  by  using  a  small  curette  to  show  its  character.  This 
in  itself  will  be  sutiicient  to  deterujine  the  diagnosis. 

Causation. — The  predisposing  causes  of  endometritis  are  imi)er- 
fections  in  the  general  organization,  and  in  the  develo-pment  and 
growth  of  the  sexual  organs.     Scrofulous  and  tuberculai"  diatheses 


INFLAMMATUKY    AFFECTIONS   OF   THE   UTERUS.  185 

incline  to  clirouic  intlaininatioii  of  the  mucous  nieinbranes  generally, 
md  the  nieiulji-aiie  of  the  uterus  is  no  exception. 

When  the  uterus  is  under  size  or  malfonned  in  a  slight  degree, 
30  that  menstruation  is  imperfectly  ]:)erformed,  an  inflammation  of 
its  mucous  membrane  is  very  likely  to  come  on  sooner  or  later.  Sed- 
entary habits  and  unsuitable  clothing,  over-fatigue  in  standing  or 
walking,  or  anything  which  interrupts  the  return  circulation  from 
the  pelvis,  predispose  to  this  affection.  So,  also,  deranged  nutrition, 
from  insufficient  nutriment  or  over-taxation,  mental  or  physical, 
which  leads  to  impoverishment  of  the  blood.  Frequent  child-ljearing 
and  prolonged  lactation  also  predispose  to  the  same  trouble.  All  these 
causes  act  to  produce  derangement  of  innervation  and  circulation, 
and  so  favor  the  develoi3ment  of  inflammation. 

The  exciting  cause  which  plays  the  most  important  part  in  endo- 
metritis is  imperfect  involution  after  confinement  or  menstruation. 
The  great  majority  of  cases  take  their  origin  from  this  imperfection 
of  the  menstrual  or  parturient  involution. 

Other  exciting  causes  which  may  be  mentioned  are  injuries  to 
the  uterus  from  displacements,  the  use  of  ill-fitting  pessaries,  injuries 
during  confinement,  causing  puerperal  inflammations;  abortion,  es- 
pecially if  produced,  intemperate  coition,  and  efforts  to  prevent  con- 
ception, and  finally  gonorrhoeal  virus.  This  specific  cause  of  endo- 
metritis no  doubt  produces  a  form  of  inflammation  which  differs 
from  the  non- specific  forms,  and  hence  we  will  refer  to  it  at  another 
time.  So  far  as  I  know  the  same  causes  produce  both  cervical  and 
corporeal  endometritis,  so  that  in  the  present  state  of  our  knowledge 
I  am  not  prepared  to  state  any  difference  in  the  causes  of  the  two 
affections,  if  any  such  exists.  I  am  inclined  to  think,  however,  that 
as  cervical  endometritis  is  beyond  doubt  much  more  common  than 
corporeal,  it  may  be  inferred  that  the  one  tends  to  the  development 
of  the  other. 

Prognosis. — Of  the  uncomplicated  cases  of  cervical  endometritis 
the  great  majority  yield  to  the  proper  treatment.  There  is  in  some 
a  tendency  to  a  recurrence  of  the  disease,  even  after  recovery  has 
apparently  been  perfect.  In  those  cases  of  imperfect  development 
there  is  not  the  same  certainty  <^f  giving  complete  relief. 

Treatment, — The  constitutional  treatment  of  inflammatory  affec- 
tions of  the  uterus  should  be  based  upon  the  principles  of  the  gen- 
eral management  of  local  inflammations.  To  correct  any  defect  in 
the  general  health,  to  imjDrove  menstruation,  and  to  calm  any  excite- 
ment of  the  nervous  system,  comprehends  the  whole  subject.  The 
sexual  organs  being  dependent  upon  the  nutritive  and  nervous  sys- 


186  DISEASES  OF  WOMEN. 

terns  for  support,  general  thrriipiutic  agents  can  only  alFcct  the  one 
by  action  through  the  otlier. 

There  are  a  few  medicines  whicli  act  especially  upon  the  sexual 
organs,  through  the  circulatory  or  nerv<nis  systems,  such  as  erg(jt, 
hydrastis  canadensis,  and  the  bromides,  but  their  etl'ects  are  not  al- 
ways ethcient  in  controlling  intlamuuitiou. 

Constitutional  i-emedies,  as  already  stated,  act  upon  the  uterus 
only  so  far  as  they  improve  general  nutrition  and  innervation.  In 
view  of  these  facts,  little  need  be  said  on  tiiis  ])art  (jf  the  subject ; 
every  means  which  can  improve  the  general  health  should  be  em- 
ployed in  connection  with  the  local  treatment.  To  save  repetition, 
the  reader  is  referred  to  the  section  on  menstrual  derangements, 
third  chapter,  for  details  of  constitutioual  derangements  which  usu- 
ally accompany  diseases  of  the  uterus. 

Local  Treatment. — Local  treatment  of  the  diseases  of  the  uttrus 
— the  one  organ  of  the  sexual  system  which  is  most  amenable  to  local 
treatment — will  be  given  in  the  history  of  cases.  Some  general  re- 
marks, however,  on  the  principal  facts  in  uterine  therapeutics  may 
be  submitted  in  this  connection.  That  which  is  said  now  will  apply 
in  great  part  to  all  forms  of  metritis. 

Local  treatment  should  be  employed  with  the  view  of  accom- 
plishing two  objects :  first,  to  remove  the  disease,  and,  second,  to 
restore  the  organ  to  its  normal  condition. 

It  will  at  once  be  inferred  that  if  the  first  object  is  attained,  the 
second  will  follow  as  a  natural  consequence ;  but  it  may  or  may  not, 
according  to  the  character  of  the  treatment  employed.  I  am  satis- 
fied that  in  times  past,  and  even  at  present,  much  of  the  treatment 
of  uterine  disease,  while  it  arrests  the  inflammatory  trouble,  provi- 
so destructive  to  the  normal  structure  of  the  organ  as  to  render  the 
last  condition  of  the  patient  v.-oi-se  than  the  first. 

In  the  management  of  uterine  diseases  one  may  be  guided  by 
some  of  the  accepted  rules  laid  down  b}'^  surgeons  for  the  treatment 
of  inflammation  generally,  viz. :  Place  the  diseased  organ  at  rest ; 
quiet  irritation  by  sedatives,  and  relieve  the  congestion  by  depletion, 
astringents,  alteratives,  and  sedatives.  To  accomplish  these  objects, 
it  is  necessary  to  employ  all  the  improved  means  brought  forward 
by  modern  investigation,  clu.nging  and  adapting  them  so  as  to  meet 
the  peculiarities  of  each  case.  First,  then,  rest  should  be  secured  by 
having  the  patient  abstain  from  long-coutiimed  standing  or  walking, 
and  from  over-excitement  of  the  sexual  function.  If  the  uterus  i> 
displaced,  it  should  be  replaced,  and  sustained  in  its  normal  position 
by  the  sui)port  of  a  well-fitting  pessaiw,  if  need  be. 


INFLAMMATORY   AFFECTIONS   OF   THE    UTERUS.  187 

To  reliev^u  ])alii  and  quiet  the  irritation  a  vaginal  <jr  rectal  sup- 
pository made  of  extract  of  belladonna,  one  eighth  to  one  half  grain, 
with  cocoa-butter,  and  used  at  bed-time,  will  often  give  great  relief. 
Suppositories  of  iodoform  and  of  conium  are  also  of  service  when 
used  in  the  same  way. 

I  desire  to  call  attention  specially  to  the  next  agent,  namely,  deple- 
tion, because  I  regard  it  is  as  a  remedy  of  some  value.  In  making  this 
statement  I  am  aware  that  I  encoimter  nnich  professional  prejudice. 
Bloodletting  has  ceased  to  be  the  fashion  of  the  day.  The  lancet  is 
condemned  as  a  "  little  instrument  of  mighty  mischief."  Few  of 
the  younger  members  of  the  pi'ofession  have  ever  seen  a  patient  bled. 
Local  depletion  held  its  own  some  time  after  general  venesection 
was  to  a  great  extent  al)andoned,  but  even  this  has  gradually  given 
way  to  the  popular  prejudice  of  the  day ;  nevertheless,  the  fact  in 
surgical  therapeutics  remains  as  true  as  ever,  that  the  removal  of 
blood  directly  from  the  vessels  of  an  inflamed  or  congested  organ 
gives  some  temporary  relief. 

Frequent  repetition  of  bloodletting  should  be  avoided,  but  when 
a  case  is  first  seen  in  which  there  is  marked  congestion,  the  abstrac- 
tion of  a  little  blood  by  a  few  punctures  around  the  os  externum,  or 
the  superficial  scarification  of  the  mucous  membrane  in  this  region 
will  pave  the  way  for  other  applications. 

To  practice  depletion  exclusively  and  persistently,  as  some  of  the 
older  gynecologists  did,  is  certainly  injurious ;  but,  as  a  means  to  be 
employed  in  suitable  cases,  it  is  worthy  of  consideration. 

Hot  water,  used  as  a  vaginal  douche,  is  an  antiphlogistic  which 
was  first  popularized  in  this  country  by  T.  A.  Emmet.  It  depletes 
the  parts  by  stimulating  the  circulation,  and  is  at  the  same  time 
something  of  a,  local  sedative.  It  is  an  exceedingl}^  popular  remedy 
at  the  present  time,  and  is  used  rather  indiscriminately  in  all  diseases 
of  the  pelvic  organs,  and  with  heroic  persistency.  If  properly  used 
it  gives  reUef  in  congestion  of  the  vagina  and  uterus,  and  in  cellulitis 
when  the  inflammation  is  limited  to  the  cellular  tissue  about  the  cer- 
vix uteri.  It  is  also  of  service  in  the  passive  congestion  which  often 
accompanies  imperfect  involution,  but  in  pelvic  peritonitis,  salpin- 
gitis, and  ovaritis  it  is  often  harmful. 

It  is  also  very  liable  to  do  harm  when  used,  as  it  often  is,  after 
plastic  operations  about  the  cervix  uteri  and  perinaeum. 

Another  means  of  depletion  was  introduced  by  J.  Marion-Sims. 
He  employed  a  small  vaginal  tampon  of  cotton  saturated  with  glyc- 
erin, which  caused  free  exosmosis  from  the  mucous  membrane,  there- 
by relieving  capillary  engorgement  and  oedema. 


188  DISEASES   OF    WOMEN. 

Position  has  iiiiich  influeiiee  in  modifying  the  circulation  in  the 
pelvis,  and  hence  jjatients  should  avoid  the  too  common  habit  of  sit- 
ting all  day  in  a  chair  hecausc  they  siilfer  when  they  walk.  Short 
periods  of  walking  or  ridiiig,  followed  by  rest  in  the  recumbent  ])o- 
sition,  should  be  directed. 

In  the  treatment  of  cudtjmetritis  with  the  application-;  of  cura- 
tive agents,  two  very  important  (pie.stions  arise  :  First,  what  agents 
shall  be  used,  and  how  shall  they  be  applied.  Bearing  in  mind  that 
the  uterus  should  not  be  injured  in  its  structure,  the  therapeutist  is 
bound  to  reject  all  the  more  powerful  and  destructive  agents,  such 
as  nitric  or  chromic  acid,  caustic  potash,  and  the  actual  cautery.  All 
these  have  been  used,  and  are  now,  though  less  extensively,  I  trust, 
than  formerly,  in  the  treatment  of  simple  chronic  endometritis,  or 
hyperaemia  of  the  mucous  membrane  of  the  cavity  of  the  uterus. 

Leaving  out  of  account  the  value  of  these  potent  agents  in  the 
treatment  of  malignant  diseases  oi  the  uterus,  I  desire  to  be  distinctly 
understood  as  opposed  to  their  use  in  the  treatment  of  the  benign 
uterine  diseases. 

I  readily  admit  that  iutiammation  of  a  mucous  membrane  can 
and  may  have  been  "  cured,"  as  the  expression  is,  by  such  means. 

The  oculist  could  '"cure"  a  chronic  coniunctivitis  bv  destrovins: 
the  membrane  Avith  strong  caustic,  but  I  fear  the  eye  would  be  hardly 
presentable  afterward,  and  it  would  surely  fail  to  perform  its  func- 
tion. There  are  those  who  treat  the  same  affections  of  the  mucous 
membrane  of  the  uterus  with  these  destructive  agents,  and  the  result- 
which  follow  can  be  easily  imagined.  It  may  be  argued,  I  am  aware, 
that  strong  caustics  are  being  used  less  and  less  by  the  profession  in 
the  treatment  of  uterine  disease,  and  1  am  glad  to  believe  that  sucli 
is  the  case.  Nitric  and  chromic  acids,  and  other  caustics,  are  being 
laid  aside,  but  only,  I  fear,  to  give  place  in  some  cases  to  new  but 
none  the  less  destructive  agents.  I  allude  to  the  galvano-cautery  and 
the  thermo-cautery.  These  have  become  the  "fashionable"  caustic- 
or  cauteries  of  the  day,  and  I  trust  I  most  thoroughly  ajipreciate  their 
value  in  the  treatment  of  malignant  disease,  Avhen  the  destruction  of  i 
tissue  is  called  for;  but,  in  the  treatment  of  inflammation,  they  can; 
not  fail  to  work  great  and  uncalled-for  destruction,  like  the  agent- 
used  in  the  past. 

The  treatment  of  the  cervical  canal  is  fortunately  simpler,  beiuL' 
n?ore  easy  to  reach,  and  much  more  tolerant  of  irritation.  The  onlv 
difficulty  in  the  way  of  making  applications  is  the  presence  of  a  tena- 
cious secretion  which  fills  the  canal.  This  should  be  removed  with 
a  small  curette  before  the  application  is  made. 


INFLAMMATORY    AFFECTIONS   OF   THE    UTERUS.  189 

Tlie  method  of  applying  these  agents  is  by  using  the  pipette 
(Fig.  100).  Regarding  the  agents  to  be  used,  a  h)ng  list  might  be 
given,   but  it    will 

suffice   to  say  that        ^^^  -■,.^,.. 

the  safest  and  most 

efficient     are     mild  Fig.  lOO. — Instillaticn  tuoc. 

solutions,  one  or  two  grains  to  the  ounce,  of  snlphate  of  ziuc,  chlo- 
ride of  zinc,  nitrate  of  silver,  tannic  acid,  and  bichloride  of  mer- 
cury ;  my  own  preference  for  general  use  is  tincture  of  iodine  two 
parts,  and  carbolic  acid  one  part. 

The  frequency  with  winch  these  local  applications  should  be  made 
depends  upon  the  nature  of  the  lesions.  In  ordinary  cervical  and 
corporeal  endometi-itis,  once  every  five  or  six  days  wall  answer.  This 
gives  time  for  the  tissues  to  fully  profit  by  the  application  before 
it  is  repeated. 

I  am  aware  that  the  practice  with  some  is  to  make  local  applica- 
tions every  day  or  every  other  day,  but  I  know  that  this  constant 
manipulation  is  irritating,  and  does  more  harm  than  good. 

ILLUSTRATIVE    CASES. 

A  Typical  Case  of  TTncomplicated  Cervical  Endometritis. — A  lady, 

I  thirty-two  years  of  age,  was  married  at  the  age  of  twenty-one,  had 
I  borne  six  children,  and  had  nursed  all  of  them.  Her  health  had  al- 
I  ways  been  very  good,  and  her  menstruation  regular  and  natural, 
:  slio\ving  that  her  general  health  and  organization  were  excellent. 
She  nursed  her  last  child  for  eighteen  months,  her  menses  returning 
when  her  child  was  ten  months  old.  From  that  time  she  had  a  slight 
leucorrhoeal  discharge  which  gave  her  no  trouble,  and  was  not  re- 
garded. Before  weaning  her  child  she  became  quite  debilitated,  com- 
plaining of  occasional  dizziness,  shortness  of  breath  in  active  exer- 
cise, considerable  backache,  constii)ation,  and  occasionally  impaired 
appetite.  Her  ieucorrhcea  about  this  time  increased  in  amount  and 
alarmed  her,  because  she  attributed  her  general  ill-feelings  to  this 
discharge.  This  was  her  condition  when  she  first  applied  for  ad\ice. 
On  digital  examination  the  uterus  was  found  to  be  normal  in  size 
and  position,  the  external  os  was  larger  than  normal,  and  there  ap- 
peared to  be  slight  roughening  of  the  membrane  immediately  around 
the  OS.  A  speculum  examination  revealed  an  areola  of  a  deep-red 
color  around  the  os  externum,  and  a  profuse  leucorrhoeal  discharge 
from  the  cervical  canal.  The  cervix  appeared  to  be  a  little  larger 
than  normal,  but  this  increase  in  size  was  wholly  due  to  enlargement 
of  the  cervical  mucous  membrane,  which  was  decidedly  congested. 


190  DISEASES  OF   WOMEN. 

and  possibly  somewhat  thickened.  The  internal  o.s  appeared  to  bo 
n(»niial ;  the  iinicoiis  niendjrane  of  the  cervix  bled  when  touched 
rather  gently  with  the  uterine  sound.  From  the  fact  that  her  men- 
strual flow  was  quite  regular  and  normal,  and  that  the  internal  os 
was  not  unduly  dilated,  nor  the  body  of  the  utenr;  enlarged  or  ten- 
der, the  diagnosis  of  endometritis  limited  to  the  cervix  was  made 
with  positiveness.  Her  general  debility  was  no  doubt  due  to  fre- 
quent child-bearing  and  lactation,  and  not  wholly  to  her  uterine  dis- 
ease, as  she  had  sup])Osed ;  in  fact,  I  believe  that  the  cause  of  the 
endometritis  was  largely,  perhaps  entirely,  due  to  her  exhausted  and 
debilitated  condition. 

She  was  directed  to  wean  her  child  as  promptly  as  possible,  and 
to  rest  from  all  her  taxing  household  duties:  to  spend  sometime 
every  day  in  the  open  air,  riding  mostl}',  and  to  take  an  abundance 
of  good  nourishing  food.  The  following  prescrii)tious  were  given 
to  her:  A  teaspoonful  of  conip.  liquorice-powder  at  bed-time,  to  be 
repeated  every  night,  the  quantity  to  be  increased  or  diminished  in 
order  to  keep  the  bowels  regular.  Two  grains  of  the  pyrophosj^hatc 
of  iron  were  given  after  meals,  well  diluted,  and  a  glass  of  claret. 
Locally,  she  was  directed  to  use  a  vaginal  douche  of  borax  and  wann 
water  twice  a  day.  This  was  continued  for  about  two  weeks,  \\lien 
it  was  found  that  she  did  not  apparently  derive  very  much  benefit  from 
it,  and  she  was  directed  to  use  it  only  once  a  day,  which  seemed  to 
answer  quite  as  well,  and  relieved  her  from  the  trouble  of  using  it 
twice  a  day,  which  she  complained  of  as  a  considerable  annoyance. 
Locally,  the  treatment  consisted  of  a  careful  removal  of  all  secretion^ 
from  the  cervical  canal  with  a  dull  curette.  In  doing  this  consider- 
able hseraorrhage  was  pi-oduced  at  first,  and  it  was  necessary  to  wait 
until  this  had  subsided  before  making  any  local  application,  but  a> 
this  only  occurred  a  few  times  it  was  soon  possible  to  remove  the 
secretions  without  difficulty,  and  a  ]ireparation  of  equal  parts  of 
tincture  of  iodine  and  carbolic  acid  was  applied  thoroughly  to  tlie 
entire  canal  with  the  glass  pipette  (Fig.  lOO).  A  few  drops  of  this 
mixture  was  drawn  up  into  the  tube  by  compressing  and  releasing 
the  bulb.  The  pipette  was  carried  up  to  the  internal  os,  and  while 
it  was  being  slowly  withdi-awn  pressure  was  made  upon  the  rublter 
bulb,  which  gently  cxjielled  this  mixture  and  thoroughly  applied  it 
to  the  entire  mucous  membrane.  This  local  treatment  was  repeated 
every  five  days  during  the  next  two  succeeding  inter-menstrual  pe- 
liods,  and  the  general  tonic  and  sustaining  treatment  continued, 
varying  the  chalybeate  tonics  from  time  to  time.  From  this  time 
onward  local  applications  were  made  after  each  menstrual  peiiod. 


INFLAMMATORY   AFFECTIONS   OF   THE    UTERUS.  191 

and  a^ain  in  alxmt  two  weeks,  making  two  local  treatments  l)etween 
each  menstrual  period.  Her  general  condition  greatly  improved; 
the  cervix  diminished  in  size  by  a  marked  contraction  of  the  cali- 
ber of  the  canal;  the  Icucorrlireal  discharge  almost  entirely  disap- 
peared, and  at  the  end  of  five  months  from  the  titne  that  the  treat- 
ment was  first  begnn  she  was  dismissed  qnite  well.  She  was  di- 
rected, howevei",  to  return  after  the  menstrual  period  for  two  or 
three  months,  to  ascertain  if  there  was  any  disposition  to  a  recurrence 
of  the  cervical  endometritis.  It  was  found  that  she  remained  well, 
and  hence  recovery  was  considered  to  be  complete. 

Cervical  Endometritis,  with  Hyperplasia  of  the  Mucous  Membrane. 
— This  patient  was  twenty- eight  years  of  age,  rather  small  and  deli- 
cate-looking, but  had  enjoyed  good  health  up  to  her  last  confinement. 
She  had  been  married  eight  years  and  had  three  children,  the  last 
one  being  ten  months  old  at  the  time  when  I  saw  her  first ;  she  had 
nursed  all  her  children,  the  first  two  for  about  a  year,  but  tlie  last 
one  she  weaned  when  it  was  eight  months  old,  because  she  did  not 
feel  well,  and  had  not  sufficient  milk  for  it.  When  her  baby  was 
about  four  months  old  she  began  to  suffer  from  leucorrhoea,  back- 
ache, and  pelvic  tenesmus — the  latter  symptoms  being  very  much 
aggravated  by  active  exercise.  She  had  also  lost  considerable  flesh, 
was  easily  fatigued,  and  somewhat  nervous  and  depressed ;  her  gen- 
eral nutrition  appeared  to  be  fair,  and  her  appetite  was  good ;  her 
bowels  were  regular,  and,  although  her  pulse  was  not  strong,  she  had 
a  good,  clear,  healthy  complexion.  Digital  examination  revealed 
slight  relaxation  of  the  vagina,  especially  of  the  upper  portion  ;  the 
uterus  was  rather  low  in  the  pelvis,  and,  while  the  body  was  normal 
in  size,  the  cervix  was  considerably  enlarged. 

The  cervical  canal  was  dilated,  and  the  lips  of  the  external  os 
everted.  Around  the  os,  and  extending  outward  to  about  half  the 
thickness  of  the  cervical  walls,  the  mucous  membrane  was  quite 
granular  and  rough  to  the  touch.  Throiigh  the  speculum  a  very  free 
leucorrhoeal  discharge  from  the  cervix  was  observed,  and  the  first 
impression  was  that  there  was  superficial  bilateral  laceration  of  the 
cervix,  but  on  more  careful  investigation  it  was  found  that  the  mus- 
cular wall  of  the  uterus  was  very  little,  if  at  all,  injured,  and  that 
the  enlargement  of  the  os  externum  and  the  eversion  of  its  lips  were 
line  to  the  enlargement  of  the  mucous  membrane. 

The  corrugations  of  the  thickened  mucons  membrane  were  so 
marked  as  to  give  a  papillomatous  ajipearance,  and  the  congestion 
was  such  that  the  parts  bled  freely  on  being  touched  with  a  sponge. 
The  patient  was  put  upon  a  systematic  course  of  rest  and  exercise, 


192  DISEASES   OI-    WOMEN. 

simple  but  nonrisliing  foixl,  and  the  citrate  of  iron  and  quinine  an  a 
tonic.  Locally,  she  was  ordered  a  vaginal  douche  of  two  quarts  of 
water,  two  drachms  of  borax,  and  a  half  drachm  of  tannic  acid  to 
be  used  twice  daily.  A  number  of  the  more  prominent  ])oint8 
of  the  mucouri  membrane,  which  j)rojected  from  the  o.s  externum, 
were  removed  with  the  scissors.  A  borated  tampon  was  introduced 
and  removed  on  the  following  day,  and  two  days  afterward  the  iodine 
and  carbolic  acid  niixture  was  applied  to  the  whole  length  of  the  cer- 
vical canal  with  the  pipette.  ( )ne  week  afterward  that  portion  of  the 
cervical  mucous  niemljrane  which  could  be  seen  was  smooth,  less  re- 
dundant and  less  vascular  ;  the  canal  was  still  dilated,  and  the  rugosi- 
ties of  the  mucous  membrane  were  abnormally  prominent.  The 
more  prominent  portions  of  the  mucous  membrane  of  the  canal  were 
touched  with  a  tifty-per-cent  solution  of  chloride  of  zinc  applied 
with  a  camel's-hair  brush.  Considerable  pain  followed  this  a|)plica- 
tion,  and  continued  until  late  in  the  evening.  From  this  onward 
the  vaginal  douche  was  employed  once  a  day,  borax  and  water  only 
being  used,  the  tannic  acid  being  omitted.  The  carbolic  acid  and 
iodine  were  applied  to  the  canal  of  the  cervix  with  the  pipette,  the 
secretion  being  carefully  removed  with  the  curette  before  the  appli- 
cation. This  local  treatment  was  employed  once  a  week  during  the 
inter-menstrual  periods  for  about  five  months,  after  that  one  appli- 
cation after  each  menstrual  period  for  three  months  longer.  At  this 
time  her  general  health  had  been  considerably  restored,  the  canal  of 
the  cervix  had  returned  to  its  normal  size,  the  leucorrhceal  discharge 
had  entirely  disappeared,  and  the  mucous  membrane  around  the  oe 
externum  was  perfectly  normal.  She  had  nf)  further  trouble  from 
backache  or  pelvic  tenesmus,  and  she  was  dismissed  perfectly  well, 
locally  and  generally. 

Cervical  Endometritis,  Stenosis  of  the  External  Os,  and  Cystic  De- 
generation of  the  Mucous  Membrane. — ^Tliis  patient  was  an  KnglisL 
lady,  thirty-nine  years  of  age.  She  had  two  children,  the  youngest 
one  being:  five  vears  old.  She  had  an  excellent  constitution,  and  her 
health  had  always  been  quite  perfect.  After  her  second  confinement 
her  convalescence  wa^  interrupted  for  a  short  time  by  some  local 
trouble,  the  nature  of  which  I  could  not  exactly  determine.  She 
recovered  from  this,  but  afterward  suffered  from  uterine  leucorrhoea 
This  gave  her  very  little  trouble,  and  as  she  hoped  that  it  might  dis- 
ap])ear  she  did  not  seek  medical  advice  until  two  years  afterwai*d, 
when  she  called  upon  a  physician,  wlio  told  her  that  "she  had  ulcer- 
ation of  the  womb."  He  treated  her  for  about  six  months  by  apply- 
ing nitrate  of  silver,  making  the  applications  with  a  swab  through  a 


INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS.  193 

cyliinlrical  speculum.     This  I  learned  from  the  patient  herself,  who 
I  stated  that  the  doctor  told  her  he  was  using  nitrate  of  silver. 

The  treatment  diminished  the  leucorrhoeal  discharge,  but  she 
:  be<nin  to  have  backache  and  pelvic,  tenesmus,  with  an  occasional 
sharp  pain  in  the  region  of  the  uterus.  She  also  had  slight  djs- 
pareunia.  She  was  told  by  her  physician  that  the  ulceration  was  cured , 
,  and  that  her  symptoms  would  all  probably  pass  away,  but  after  wait- 
ing for  six  months  and  finding  that  they  did  not  she  came  under 
i  my  observation.  Her  general  health  was  still  fairly  good,  but  the 
;  local  symptoms  caused  her  considerable  nervous  disturbance,  and  the 
I  leucorrha?a  had  returned,  but  not  so  profusely  as  before.  The  touch 
I  revealed  an  enlargement  of  the  cervix  uteri,  and  around  the  os  there 
,  was  a  number  of  quite  hard  points,  some  of  them  projecting  a  little 
■  above  the  general  surface,  giving  an  impression  that  there  was  a 
number  of  shot  imbedded  in  the  cervix.  The  os  externum  could 
:■  not  be  very  clearly  made  out  by  the  touch.  The  entire  cervix  ap- 
I  peared  to  "be  a  little  denser  than  normal,  and  on  speculum  exami- 
I  nation  the  nmcous  membrane  seemed  to  be  red  in  spots,  while  the 
i  cysts  had  a  whitish  or  pearly  appearance,  some  of  them  showing  a 
'  deep-yellow  color.  The  os  externum  was  somewhat  puckered  from 
I  sear  tissue,  one  well-marked  scar  running  from  the  posterior  lip  of 
I  the  os  outward  and  backward.  This  was  lighter  in  color  than  the 
I  general  mucous  membrane.  The  os  admitted  a  small  uterine  probe. 
1  The  canal  of  the  cervix,  above  the  contracted  os  externum,  was  found 
j  to  be  considerably  dilated,  and  contained  quite  a  large  accumulation 
!  of  a  thick,  tenacious,  leucorrhoeal  secretion.  The  cervix  was  tender 
i^;o  the  touch,  but  not  extremely  so  ;  the  body  of  the  uterus  appeared 
to  be  normal  in  every  way. 

The  conditions  here  found  illustrate  a  very  common  class  of  cases 
;  in  which  there  has  been  ordinary  cervical  catarrh,  which  has  been 
i  treated  by  the  application  of  a  caustic  to  the  vaginal  surface  of  the 
i   cervix  and  the  lips  of  the  os  externum. 

The  frequent  and  long-continued  use  of  nitrate  of  silver  almost 
1  always  produces  stricture,  scar  tissue,  occlusion  of  the  Kabothian 
\  glands,  and  the  formation  of  cysts.  The  treatment  in  this  case 
I  was  to  first  take  out  a  triangular  piece  of  the  scar  tissue  from  each 
i  side  of  the  os  externum,  which  enlarged  it  sufficiently.  The  cysts 
i  were  then  all  carefull}"-  torn  open,  and  the  contents  evacuated  by 
I  pressure ;  the  secretion  in  the  cervical  canal  was  removed  with  the 
curette,  and  an  application  of  the  tincture  of  iodine  was  made  to  the 
f  canal  and  the  vaginal  portion  of  the  cervix.  A  hot-water  douche 
I  was  directed  to  be  used  twice  a  day.  The  patient  was  examined 
u 


19i  DISEASES   OF   WOMEN. 

three  days  after,  when  the  os  exteniiini  was  observed  to  be  contract- 
ing somewhat  lus  the  liealiii*^  process  was  going  on.  A  small  tampon 
of  cotton  was  introduced  into  the  os  externum,  and  nuuntained  there 
for  twenty-four  hours  by  means  of  the  vaginal  tampon.  ]t  was  then 
reintroduced  without  the  vaginal  tampon,  and  again  removed  at  the 
end  t>f  the  next  twenty-four  hours.  This  tampon,  while  it  j)re- 
vented  the  contraction  of  the  os,  interfered  at  the  same  time  with 
the  process  of  healing,  so  it  was  given  up.  At  the  end  of  a  week 
after  the  tirst  treatment  there  was  found  still  a  number  of  cysts, 
some  of  them  within  the  cervical  canal.  These  were  all  opened  and 
the  leucorrhoeal  secretion  remcjved  from  the  canal  with  the  curette, 
and  the  mixture  of  iodine  and  carbolic  acid  applied  ;  and  tincture  of 
iodine  alone  applied  to  the  vaginal  portion  of  the  cervix. 

These  applications  were  repeated  once  a  week,  and  the  warm- 
water  douche  continued  for  four  months.  During  this  time  aU 
the  local  symptoms  disappeared  except  the  leucorrhceal  discharge, 
and  this  diminished  in  quantity  and  became  less  opaque  in  character, 
but  it  did  not  wholly  disappear. 

The  size  of  the  external  os  remained  ample,  while  the  canal  con- 
tracted very  decidedly,  so  that  it  was  almost  of  its  normal  caliber. 
The  scar  tissue  became  less  dense,  and  all  tenderness  disap])eared. 
After  the  first  four  months'  treatment  the  patient  was  seen  for  an- 
other three  months,  just  after  the  menstrual  period,  when  the  iodine 
and  carbolic  acid  were  applied  to  the  cervical  canal,  and  the  iodine 
to  the  vaginal  portion  of  the  cervix.  Seven  months  from  the  time 
that  she  first  came  under  my  observation  she  Avas  found  to  be  preg- 
nant, and  hence  was  dismissed  as  recovered.  I  subsequently  learned 
that  she  passed  safely  through  her  confinement,  but  1  have  had  no 
opportunity  of  examining  her  since,  although  I  believe  that  she  re- 
mains quite  well,  and  hence  it  can  be  inferred  that  the  cure  was 
quite  permanent. 

Cervical  Endometritis  treated  by  Caustic,  which  produced  Con- 
traction of  the  lower  two  thirds  of  the  Cervical  Canal. — This  lady 
was  twenty-eight  years  of  age,  of  remarkably  strong  orgauization, 
and  had  always  enjoyed  good  health  until  the  birth  of  her  tliird 
child.  At  that  time  she  had  some  ditiiculty  in  her  labor,  and  sus- 
tained a  slight  laceration  of  the  perin.neum ;  after  this  she  had  pelvic 
tenesmus  and  leucorrlnea.  When  she  first  came  under  my  observa- 
tion she  had  slight  prolapsus  of  the  uterus,  with  rctrovei'sion  in  the 
first  degree ;  there  was  cervical  endometritis,  indicated  by  the  deep- 
red  color  of  the  mucous  membrane  and  free  leucorrluea,  but  there 
was  no  other  jjathological  change  in  the  mucous  membrane.     An 


INFLAMMATORY   AFFECTIONS   OF   THE   UTERUS.  195 

application  of  tannin  and  glycerin  was  made  to  the  cervical  canal, 
the  uterus  was  replaced,  and  she  was  told  that  it  would  be  necessary 
to  restore  the  perinaeum  in  order  to  give  complete  relief.  The 
thought  of  an  operation  somewhat  disturbed  her  mind,  and  a  friend 
advised  her  to  place  herself  under  the  care  of  her  physician,  a  liomre- 
opathist.  This  she  did,  and  at  the  second  visit  he  told  her  that  he 
had  introduced  a  pencil  of  nitrate  of  silver  into  the  womb,  and  had 
applied  some  cotton  to  keep  it  there,  and  desired  her  to  return  to 
his  office  the  next  day  so  that  he  might  remove  the  cotton.  On  the 
way  home  she  suffered  severe  pain,  and  was  obliged  to  go  to  bed  as 
soon  as  she  reached  the  house.  She  suffered  considerably  during 
the  night,  and  the  following  day  sent  for  the  physician,  who  removed 
the  cotton,  and  told  her  that  she  would  be  all  right.  She  continued, 
however,  to  have  a  good  deal  of  pain  and  pelvic  tenesmus,  especially 
when  she  tried  to  stand  or  walk.  For  the  next  two  or  three  days 
she  had  a  discharge  which  differed  from  the  former  leucorrhoea ;  it 
was  less  tenacious,  yellow  in  color,  and  at  times  quite  offensive  in 
odor.  She  returned  to  the  physician  for  further  treatment  as  soon 
as  she  was  able.  The  discharge  became  very  much  less,  and  finally 
disappeared  entirely.  She  was  encouraged  to  hope  that  she  would 
get  well  without  any  further  treatment.  In  this,  however,  she  was 
misled.  Her  backache  and  pelvic  tenesmus  increased  in  severity, 
especially  when  standing  or  walking,  and  she  began  to  have  painful 
menstruation.  About  a  year  from  the  time  she  had  the  caustic  ap- 
plied she  returned  to  me.  I  found  the  displacement  about  the 
same ;  there  was  no  leucorrhoeal  discharge  whatever,  and  no  external 
evidence  of  the  former  endometritis.  The  os  externum  was  con- 
tracted, and  its  lips  curved  inward ;  the  tissues  around  the  os  were 
extremely  hard,  and  to  the  touch  and  inspection  appeared  to  be  mostly 
scar  tissue. 

The  cervical  canal  was  contracted  in  its  lower  two  thirds,  so  that 
'  a  small  uterine  sound  could  be  passed  with  difficulty ;  there  was 
none  of  the  elasticity  of  the  normal  canal  left,  but  a  hard,  almost 
cartilaginous  condition  existed.  The  passing  of  the  sound  caused 
considerable  pain,  and  some  haemorrhage.  The  patient  was  then 
sent  to  my  private  hospital,  and  an  effort  was  made  to  dilate  the 
cervix  by  the  use  of  graduated  sounds.  This  gave  pain,  and  was 
not  effectual.  Then  the  whole  length  of  the  contracted  portion  of 
the  cervical  canal  was  incised  on  the  two  sides,  the  incisions  being 
made  with  my  hysterotome  (Fig.  46)  through  the  scar  tissue,  and 
the  canal  was  then  dilated  sufficiently  to  admit  a  No.  23  sound ; 
a  tent  made  of  marine  lint  and  dipped  in  carbolic  acid  and  glycerin. 


196  DISEASES  OF  WOMEN. 

ODe  part  of  the  former  to  three  of  the  latter,  was  passed  up  into  the 
canal  and  retained  there  by  a  vaginal  tampon ;  this  was  left  in  jjo- 
sition  for  twenty-four  hours,  when  it  was  removed.  A  short,  hard- 
rubber  stem-pessary,  which  reached  beyond  the  line  of  contracti(»n, 
but  not  up  to  the  internal  os,  was  introduced  and  worn  for  nearly 
three  weeks.  During  that  time  it  was  repeatedly  removed  and  tinct- 
ure of  iodine  applied  to  the  cervical  canal,  and  a  vaginal  douche  of 
borax  and  warm  water  was  used.  The  treatment  was  continued 
throughout  with  all  antiseptic  i)recautions.  After  the  operation  on 
the  cervix  the  uterus  was  kept  in  place,  first  by  means  of  a  tan)j»on, 
and  subsequently  by  means  of  the  pessary,  which  answered  the 
purpose  while  the  patient  remained  in  a  recumbent  position.  The 
pei'ini^um  was  then  restored,  and  the  patient  disnussed  after  two 
months  of  treatment  in  the  institution.  She  subsequently  returned 
to  me  once  a  month,  when  I  passed  the  uterine  sound  and  applied 
the  tincture  of  iodine,  in  order  to  prevent  any  recurrence  of  the  con- 
traction. Six  months  from  the  time  that  she  was  operated  upon  she 
became  pregnant,  and,  although  some  trouble  was  anticipated  in  the 
dilatation  of  the  cervix  during  her  labor,  there  was  none.  Prof. 
Charles  Jewett  attended  her  in  her  confinement,  and  all  went  well, 
and  she  has  remained  free  from  uterine  trouble  ever  since. 

Cervical  Endometritis  in  an  Imparous  Woman. — This  was  a  cul- 
tivated lady,  with  an  excellent  constitution,  who  began  to  menstruate 
at  fourteen,  while  she  was  a  school-girl,  and  continued  to  do  so  nor- 
mally until  she  had  been  teaching  several  years  in  a  high  school 
She  taught  many  hours  daily,  and  being  strong  and  very  ener- 
getic she  preferred  to  stand,  as  a  rule,  while  drilling  her  class.  This 
overtaxation  brought  on  dysmenorrhc^a,  backache,  and  leucorrh«ea. 
These  symptoms  were  not  marked  at  first,  but  as  she  kept  on  at  her 
work  they  gradually  increased.  When  she  was  twenty-eight  years 
of  age  she  came  under  my  care.  She  had  then  been  married  about 
one  year,  and  although  her  symptoms  had  not  increased — in  fact, 
she  had  enjoyed  better  health  after  being  relieved  from  her  arduous 
duties  as  a  teacher — still  she  had  backache  and  leucorrhrea,  especially 
on  taking  active  exercise ;  and  she  was  sterile.  I  found  the  men- 
strual function  perfectly  normal,  except  that  she  had  backache  and 
some  pelvic  tenesmus  during  the  flow,  but  these  were  relieved  to 
some  extent  if  she  kept  quiet.  Her  chief  symptom  at  that  time  was 
a  rather  free  leucorrhoea.  A  digital  examination  found  the  pelvic 
organs  well  developed.  There  was  no  tenderness  nor  any  evidence 
of  disease  that  could  be  obtained  by  the  touch,  except  that  the  os 
externum  appeared  to  be  larger  than  is  usually  found  in  the  virgin 


INFLAMMATORY   AFFECTIONS   OF   TOE   UTERUS.  197 

cervix.  On  speciilmn  examination  quite  a  free  leucorrliocal  dis- 
cbarge was  observed,  and  there  was  a  ring  of  deep-red  color  in  the 
raucous  membrane  around  the  os  externum.  The  cervix  was  rather 
large  in  proportion  to  the  body  of  the  uterus,  and  was  of  a  deeper  color 
than  normal,  and  the  upper  portion  of  the  vagina  also  was  congested. 
The  canal  of  the  cervix,  including  the  internal  os,  was  normal  in 
size,  so  that  the  uterine  sound  could  be  passed  to  the  fundus  without 
difficulty  or  causing  much  pain.  As  her  health  was  quite  good,  no 
constitutional  treatment  was  necessary.  During  the  succeeding  two 
months  six  applications  of  iodine  and  carbolic  acid  were  made  to  the 
cervical  canal.  The  next  month  three  applications  were  made  of 
iodine  alone,  and  the  next  month  after  that  glycerin  and  tannic  acid 
were  applied.  At  the  end  of  that  time  the  leucorrhoeal  discharge 
had  entirely  subsided,  the  patient  suffered  much  less  from  backache, 
and  had  no  pain  or  discomfort  at  lier  menstrual  periods.  She  was 
then  dismissed,  and  nothing  more  was  heard  of  her  until  four  years 
afterward,  when  she  returned  to  inform  me  that  she  was  two  months 
pregnant.  I  have  not  seen  her  since,  but  have  heard  through  her 
family  that  she  was  delivered  of  a  healthy  child  after  a  somewhat 
tedious  labor. 

Cervical  Endometritis  in  an  Imperfectly  Developed  Uterus. — This 
lady  appeared  to  be  rather  frail,  but  had  always  enjoyed  good  health. 
She  began  to  menstruate  first  at  thirteen,  and  for  the  first  year  was 
rather  irregular,  and  always  had  some  pain  the  first  day.  The  flow 
lasted  only  from  two  to  three  days,  and  the  dysmenorrhoea  increased 
somewhat  from  month  to  month ;  and  she  began  to  have  backache 
before  and  after  menstruation,  with  occasional  leucorrhoea.  When  she 
was  twenty-four  years  old  she  was  married,  but  from  that  time  onward 
her  dysmenorrhoea  increased  ;  she  had  almost  continuous  backache, 
and  a  good  deal  of  tenesmus,  with  occasional  attacks  of  frequent 
urination.  One  year  after  her  marriage  she  came  under  my  observa- 
tion, and  I  found  the  uterus  rather  below  the  normal  size  ;  there  was 
slight  anteflexion  of  the  cervix,  but  the  body  of  the  uterus  was  in  its 
normal  position.  The  uterus  was  tender  to  the  touch,  and  there  was 
also  some  hyperesthesia  of  the  vagina.  A  speculum  examination 
revealed  a  general  conarestion  of  the  cervix  and  va2:ina,  the  cervix 
being  smaller  than  it  ought  to  be ;  the  os  externum  was  small,  and 
while  there  was  a  slight  vaginal  leucorrhcea  there  was  no  discharge 
from  the  cervix.  The  canal  of  the  cervix  was  quite  large  in  propor- 
tion to  the  size  of  the  external  os,  and  the  os  internum  was  so  small  that 
an  ordinary-sized  uterine  sound  was  passed  with  difiiculty,  and  caused 
pain.     The  canal  of  the  cervix  contained  a  plug  of  very  thick,  dai'k- 


19S  DISEASES   OF    WOMEN. 

colored,  and  very  tenacious  secretion.  This  was  removed  with  the 
curette,  but  with  fi^reat  ditiiculty,  ami  (juite  a  free  hiL'inorrlia<;e  oc- 
curred during  its  removal.  After  removing  this  secretion  very  care- 
fully, and  waiting  until  all  haemorrhage  had  subsided,  a  mixture  of 
carbolic  acid,  glycerin,  and  water  was  carefully  applied  to  the  entire 
canal  fur  the  purpose  of  neutralizing  any  septic  material  which  might 
exist  there.  A  small  V-shaped  piece  was  removed  from  each  side 
of  the  cervix  at  the  os  externum,  and  four  very  su])erficial  incis- 
ions were  made  at  the  os  internum.  The  uterine  dilator  was  then 
introduced,  and  the  os  internum  and  externum  dilated  until  a  No.  9 
sound  could  be  easily  introduced.  The  patient  was  kept  quiet  in  bed 
for  several  days,  and  as  tliere  was  no  constitutional  or  local  disturbance 
at  the  end  of  that  time  she  was  allowed  to  get  up  and  go  about  again. 
From  this  time  onward  for  about  three  months  the  uterine  sound 
was  passed  once  a  week  to  prevent  contraction  of  the  cervical  cauaL 
At  the  same  time  the  secretion  was  carefully  removed  from  the  car 
nal,  and  carbolic  acid  and  tincture  of  iodine — one  part  of  the  fcjrmer 
to  two  of  the  latter — were  thoroughly  applied.  A  vaginal  injection 
was  ordered  of  one  quart  of  warm  water  and  forty  grains  of  sulphate 
of  zinc,  to  be  used  once  a  day.  The  effect  of  this  treatment  was  to 
relieve  the  dysraenorrhoea,  backache,  and  general  feeling  of  discom- 
fort in  the  pelvis. 

The  leucorrhreal  discharge  became  more  free,  somewhat  lighter  in 
color,  and  less  tenacious.  The  application  of  iodine  and  carbolic  acid 
was  continued  for  two  months  longer,  when  all  treatment  was  sob- 
pended  for  three  months.  At  the  end  of  that  time  she  returned, 
and  stated  that  her  leucorrlia?a  remained  the  same,  although  others 
wuse  she  felt  tolerably  well.  In  passing  the  sound  the  canal  of  the 
cervix  was  found  to  be  ample,  but  the  character  of  the  secretion  had 
returned  to  what  it  was  when  she  lirst  came  under  my  observation. 
I  made  applications  of  the  tincture  of  iodine  to  the  cervical  canal 
for  about  two  months,  without  ai")parently  improving  the  condition; 
I  then  tried  a  10-per-cent  solution  of  chloride  of  zinc,  applying  it 
once  a  week,  but  without  improving  the  case.  I  then  decided  to 
remove  a  longitudinal  strip  from  each  side  of  the  mucous  membrane 
of  the  cervical  canal ;  this  was  accomplished  by  seizing  the  cervix 
with  a  tenaculum,  and  then   passing  a  small-sized   Sims's  curette 


&S\tN\KV\H«»W. 


I 

Fir.   1(11.  ^ 

(Fig.  101)  up  to  tlie  internal  os,  and  under  strong  pressure  draw- 
ing it  down  and  cutting  out  a  deep  strip  of  the  mucous  membrane. 


INFLAMMATORY   AFFECTIONS   OF   TUE    UTERUS.  199 

This  was  repeated  on  the  opposite  side.  The  idea  of  removing  the 
two  sections  rather  than  removing  the  entire  membrane,  as  recom- 
mended by  Sims,  Thomas,  and  others,  was  to  leave  a  portion  of  the 
membrane,  which  would  expand  as  healing  took  place,  and  in  that 
way  compensate  for  the  loss  of  tissue,  and  thereby  prevent  the  oc- 

i  currence  of  stricture  of  the  canal  by  contraction.  During  the  heal- 
in""  process  the  uterine  sound  was  cautiously  passed  about  every  tliird 
day.  This  at  first  caused  some  haemorrhage  and  pain,  but  soon  it 
could  be  done  without  trouble  of  either  kind  resulting  from  it.  The 
applications  of  iodine  were  again  begun  and  continued  for  about 
two  months,  six  applications  in  all  being  made.  The  final  effect 
of  this  was  to  control  the  leucorrhoea,  and  the  little  discharge  that 
remained  became  more  transparent  and  less  tenacious — more  like 
the  normal  secretion  of  the  Nabothian  glands.  She  was  then  dis- 
missed apparently  well,  and  she  remained  so,  but  continued  to  be 
sterile. 

I  have  treated  a  large  number  of  cases  of  this  class  in  the  same 
way,  except  that  I  have  not  lost  time  in  trying  different  applications, 

1  but  have  removed  the  sections  of  the  mucous  membrane  at  the  out- 
set. Two  of  my  patients  have  subsequently  borne  children  ;  several 
of  them  have  had  some  contraction  of  the  canal,  which  had  to  be 
relieved  by  dilatation.  In  quite  a  number  of  them  the  leucorrhoea 
has  returned,  and  while  I  have  been  able  to  keep  them  comfortable 
by  occasional  treatment,  they  have  never  completely  recovered. 

Cervical  Endometritis  in  a  Young  Girl,  with  Marked  Thickening 
of  the  Mucous  Membrane  of  the  Cervix,  Dilatation  of  the  External  Os, 
and  Eversion  of  the  Mucous  Membrane. — This  girl  was  rather  small, 
delicate,  of  marked  nervous  temperament,  and  highly  cultivated. 
Her  circumstances  were  such  that  she  had  been  able  to  obtain  an 

I  excellent  education  and  every  advantage  and  accomplishment  that 
she  could  desire.  She  was  precocious,  and  began  to  menstruate 
when  she  was  eleven  and  a  half  years  old.  She  had  always  suffered 
slight  pain  during  her  menses,  and  also  had  leucorrhoea,  which  was 
trivial  at  first.  She  had  suffered  much  from  backache,  headache, 
and  general  debility,  but  was  able  to  attend  to  her  education  until 
she  was  sixteen  years  old.  Her  leucorrhcea  at  that  time  became 
quite  profuse,  and  her  backache  and  pelvic  tenesmus  so  severe  that 
she  was  obliged  to  give  up  muscular  exercise  almost  altogether. 
During  this  time  she  had  been  treated  with  tonics,  and  change  of  air. 
At  the  age  of  eighteen  she  was  placed  under  the  care  of  a  physician 
m  New  York,  wiio  said  that  she  had  some  falling  of  the  womb,  and 
treated  her  by  tamponing  the  vagina  with  cotton,  after  the  method 


200  DISEASES   OF   WOMEN. 

of  Boseman,  who,  I  believe,  calls  tliis  metliod  of  treatment  "column- 
in<j;  the  va^inu/- 

She  derived  no  benelit  from  this,  although  it  was  continued  for 
several  months.  In  fact,  she  became  much  worse.  She  was  then 
placed  nnder  my  care,  when  she  wsis  nineteen  years  of  age ;  her 
general  condition  at  that  time  was  one  of  marked  neurasthenia.  Her 
extremities  were  cold  and  clammy,  her  pulse  was  feeble  and  rapid; 
her  pupils  were  M'idely  dilated,  and,  while  she  was  naturally  of  a 
pleasant  and  happy  disjiosition,  she  became  apjirehensive  of  trouble, 
and  spent  most  of  her  time  in  thinking  and  talking  about  her 
symptoms.  Some  times  she  was  dull  and  sleepy,  at  other  times 
wakeful  and  sleepless ;  her  appetite  was  capricious — at  times  good, 
and  at  other  times  poor ;  her  bowels  were  constipated  ;  she  was  quite 
emotional,  and  easily  affected  to  tears  by  either  pleasant  or  unj)leasant 
mental  impressions. 

The  utenis  was  found  in  its  normal  position,  its  body  normal  in 
size  and  shape,  and  not  especially  tender ;  the  ovaries  wei'e  tender ; 
the  cervix  was  quite  enlarged,  and  to  the  touch  gave  the  usual  phys- 
ical signs  of  a  cervix  that  has  sustained  a  bilateral  laceration  super- 
iicially,  or  sutKcient  to  give  rise  to  ectropion,  as  it  is  now  called. 

The  vagina  and  vulva  were  quite  relaxed,  due,  I  presume,  to  the 
long-continued  use  of  the  tampon  ;  at  least,  I  know  of  no  other  reftf 
son  for  this  condition,  although  she  was  cHdently  of  an  amorous 
disposition,  and  no  doubt  suffered  from  physiological  congestion  of 
the  sexual  organs.  I  have  no  reason  to  believe  that  she  had  ever 
abused  herself  or  been  abused,  unless  this  tamj)oning  treatment  under 
the  circumstances  may  be  called  abuse. 

The  speculum  revealed  a  large  cervix,  looking  quite  like  that  of 
a  M'oman  who  had  borne  children.  There  was  well-marked  evei-sion 
which  brought  into  view  anteriorly  and  posteriorly  about  half  an 
inch  of  the  cervical  mucous  membrane,  which  was  easily  recognized 
as  such  by  its  rugous  arrangement,  and  the  ]')resence  of  the  Na- 
bothian  glands,  which,  though  they  could  not  be  seen,  were  proved 
to  be  present  at  that  point  by  the  secretion  which  was  freely  poured 
out  on  the  exposed  surface. 

The  most  careful  examination  failed  to  find  any  injury  of  the 
muscular  w'alls  of  the  cei-vix  showing  that  the  case  was  one  of  ever- 
sion  of  the  cervical  mucous  membrane.  This  patient  entered  my 
private  institution,  and  was  treated  generally  by  rest,  massage,  baths, 
and  careful  attention  on  the  part  of  the  nurse,  with  a  view  to  im- 
proving her  mental  condition  by  diverting  her  mind  from  hei-self, 
and  fully  occupying  her  time  with  the  treatment.     The  bowels  were 


J 


INFLAMMATORY  AFFECTIONS  OF  THE   UTERUS.  201 

kept  regular  with  a  laxative  pill ;  sleep  was  secured  by  a  dose  of 
bromide  in  the  afternoon,  and  another  at  bed-time  when  necessary  ; 
and  one  ninetieth  of  a  grain  of  the  hydrobromide  of  hyoscine  was 
given  three  times  a  day,  with  the  effect  of  improving  her  nervous 
system.  A  vaginal  douche  was  given  once  a  day,  consisting  of  sixty 
grains  of  sulphate  of  zinc  to  a  quart  of  warm  water.  This  had  the 
effect  of  overcoming  the  vaginal  relaxation  after  a  time.  Three 
weeks  after  she  came  under  my  care  her  general  health  had  improved 
noticeably,  and  she  passed  through  her  menstrual  period  with  less 
pain.  I  then  removed  the  everted  portion  of  the  mucous  membrane, 
being  careful  not  to  make  the  exsection  entirely  circumscribe  the 
OS  externum.  On  the  sides,  where  the  eversion  was  less  marked, 
portions  of  the  membrane  were  left  untouched.  This  was  done  to 
avoid  stricture,  which  I  presumed  might  occur  after  healing.  The 
.  exsection  was  made  with  the  scissors,  and  though  there  was  consid- 
,  erable  hoemorrhage,  this  was  controlled  by  the  application  of  pledgets 
of  cotton  dipped  in  chloride  of  iron,  and  kept  in  place  by  tampon- 
ing. When  the  tampon  was  removed  the  douche  of  zinc  solution 
was  resumed,  and  once  a  week  thereafter  iodine  and  carbolic  acid 
were  applied  to  the  cervical  canal.  As  the  healing  progressed  the 
external  os  contracted,  and  the  caliber  of  the  canal  diminished ;  the 
leucorrhoeal  discharge  also  subsided,  and  at  the  end  of  three  months 
the  local  trouble  had  entirely  disappeared,  and  the  cervix  looked  like 
a  virgin  cervix,  except  that  the  os  was  somewhat  larger  and  oblong 
instead  of  circular.  Her  general  health  greatly  improved,  and  she 
was  soon  able  to  take  gymnastic  exercise  and  cold  baths,  and  to  walk 
and  ride  in  the  open  air. 

She  was  dismissed  quite  well,  and  has  remained  so. 


CHAPTER  X. 

COEPOKEAL    ENDOMETRITIS. 

The  most  conflicting  views  are  to  be  found  in  the  literature  of 
medicine  regarding  the  relative  frequency  of  corporeal  and  cervical 
endometritis.  Much  of  this  division  of  opinion  comes,  no  doubt, 
from  imperfect  knowledge  regarding  the  diagnosis  of  corporeal  endo- 
metritis. 

The  facts  appear  to  be  as  follows :  That  corporeal  endometritis  is 
not  so  often  seen  as  cervical ;  that  either  may  occur  alone  ;  that  they 
may  occur  together ;  and  that  corporeal  endometritis  alone  is  most 
rare  of  all.  These  facts  have  been  obtained  from  long-continued 
observation  in  a  very  large  field,  and  I  feel  confident  of  accuracy  in 
the  facts,  because  1  have  given  due  attention  to  the  means  and 
methods  of  diagnosis — the  only  way  to  arrive  at  correct  conclusions. 

There  is  another  cause  of  confusion  on  this  subject  growing  out 
of  imperfect  methods  of  investigation,  and  that  is,  classing  under  the 
head  of  metritis  some  widely-differing  pathological  conditions,  such, 
for  example,  as  the  changes  in  the  tissues  following  the  acute  puer- 
peral affections  of  the  uterus. 

It  will  be  seen  by  M'hat  follows  that,  although  the  diagnosis  of 
metritis  is  diflScult,  careful  attention  to  that  jiart  of  the  subject  will 
secure  a  degree  of  accuracy  which  has  not  been  heretofore  generally 
attained. 

Pathology. — The  pathology  of  corporeal  endometritis  is  doubt- 
less the  same  in  character  as  that  of  cervical  endometritis,  but  un- 
fortunately there  are  not  the  same  opportunities  of  observing  the 
changes  which  take  place  in  the  mucous  membrane  as  in  the  cervical 
form.  On  this  account  post-mortem  examinations  are  the  chief 
sources  of  knowledge  of  the  pathology,  and  as  this  disease  is  never 
fatal  an  opj)ortunity  of  examining  the  uterus  only  occurs  when  pa- 
tients with  endometritis  die  of  some  other  affection,  hence  the  inex- 
act knowledge  on  this  subject. 


CORPOREAL  ENDOMETRITIS,  203 

There  is  also  a  marked  liability  to  error  in  post-mortem  investi- 
eations  of  the  endometrium.  In  constitutional  diseases,  which  prove 
fatal,  there  are  certain  changes  in  the  mucous  membrane  of  the  nte- 
rus  which  resemble  those  of  endometritis,  yet  they  are  not  exactly 
the  same,  and  do  not  represent  the  anatomical  lesions  of  uncomj^li- 
cated  endometritis,  and  should  not  be  taken  for  such. 

The  facts  regarding  the  pathology  of  corporeal  endometritis  which 
appear  quite  definitely  settled  are  as  follows  :  In  some  eases  there  is 
a  general  congestion  and  thickening  of  the  entire  membrane,  the 
lesions  of  vascularity  extending  to  the  glands  of  the  uterus.  This 
gives  rise  to  increased  nutritive  activity  on  the  part  of  these  glands, 
and  hypersecretion.  I  am  not  at  all  satisfied,  however,  that  the  dis- 
charge from  these  glands  is  exactly  the  same  as  it  is  from  the  cervix. 
I  am  inclined  to  think  that  it  is  more  serous,  less  tenacious,  and  more 
frequently  contains  blood  than  that  from  the  cervical  glands.  The 
whole  mucous  membrane  may  be  denuded  of  its  epithelium,  or  it 
may  be  so  only  in  parts ;  and,  again,  the  congestion  appears  to  be 
greater  in  spots,  and  in  these  places  there  is  thickening  of  the  mem- 
brane. These  thickened  red  patches  are  generally  found  at  the 
mouths  of  the  glands.  ]^ot  infrequently  there  are  proliferations  of 
the  mucous  membranes,  polypoid  in  character — a  condition  which  is 
sometimes  called  "  endometritis  polyposa."  This  new  product  is  one 
of  the  most  common  results  of  endometritis  of  long  standing. 

Sometimes  the  walls  of  the  uterus  are  found  thickened  so  that 
the  whole  uterus,  as  well  as  its  cavity,  is  enlarged.  In  other  cases 
the  walls  of  the  uterus  have  been  found  diminished  in  thickness, 
and  changed  in  structure  by  fatty  degeneration.  These  changes 
iu  the  walls  of  the  uterus  may  or  may  not  be  due  to  the  endo- 
metritis. 

Corporeal  endometritis  belongs  to  that  class  of  inflammations  in 
which  the  process  does  not  pass  through  its  various  stages,  and  then 
end  in  recovery,  with  or  without  permanent  changes  of  structure. 
In  this  it  differs  from  acute  inflammations,  which  begin  and  run 
through  all  their  stages,  and  end  in  recovery. 

If  once  well  established,  the  inflammation  shows  very  little  tend- 
ency to  recover  without  treatment ;  hence  it  is  that  the  cases  are 
often  found  that  begin  in  early  life,  and  continue  up  to  the  meno- 
pause. There  is  very  little  tendency  in  the  natural  history  of  these 
affections  to  become  worse  or  change  their  character;  they  often  re- 
main the  same,  excepting  that  the  constitutional  disturbance  may 
increase,  and  the  patient  fail  in  general  health. 

Symptomatology. — Owing  to  the  fact  that  the  diagnosis  of  cor- 


204  DISEASES   OF   WOMEN. 

poreal  endometritis  is  difficult,  it  is  very  necessary  to  give  close  atten- 
tion to  the  evidence  presented. 

The  sjniptoms  of  this  affection  are  well  marked,  and,  although 
not  diagnostic,  they  are  of  great  value  when  taken  in  connection 
with  the  physical  signs.  They  naturally  arrange  themselves  into 
two  classes — constitutional  and  local. 

The  constitutional  symptoms  are  manifested  by  the  nervous  sya- 
tem  and  digestive  organs.  There  is  frequently  capricious  appetite, 
tlatuleuce,  and  constipation.  The  derangement  of  the  stomach  is 
irregular,  often  varying  in  a  day,  showing  that  it  is  a  reflex  nervoug 
disturbance,  not  unlike  that  wliich  occurs  in  gestation.  The  mam- 
mary glands  are  often  sympathetically  affected,  becoming  enlarged 
and  tender,  and  the  areola  takes  on  a  darker  color.  These  symp- 
toms, taken  in  the  aggregate,  resemble  very  closely  those  found  in 
sj^urious  pregnancy,  excepting  that  the  mental  obliquity  is  absent 
It  will  be  seen  that  the  symptoms,  including  the  derangement  of  till 
digestive  organs,  are  all  such  as  might  be  expected  from  reflex  nerv- 
ous derangement,  and  such,  no  doubt,  is  their  explanation. 

I  am  aware  that  the  symptoms  here  given  have  all  been  said  to 
occur  in  cervical  eudometritis,  but,  while  there  may  be  some  slight 
constitutional  disturbance  from  this  affection,  it  is  never  so  well  de- 
fined as  in  corporeal  endometritis. 

Symptoms  referable  to  the  general  nervous  system,  which  occur 
in  this  affection,  are  not  diagnostic,  yet  they  are  valuable  when  taken 
in  connection  with  the  rest  of  the  history. 

Headache,  sleeplessness,  mental  depression,  and  jiains  in  the  spi- 
nal cord,  are  often  present,  but  I  know  of  no  special  nerve  symptoms 
peculiar  to  corporeal  endometritis.  Among  the  local  symptoms  the 
most  important,  by  far,  is  derangement  of  tlie  menstrual  function. 
This  I  consider  the  symptom  by  which  the  differential  diagnosis  be- 
tween cervical  and  corporeal  endometritis  can  be  made,  and  therefore 
it  should  be  borne  in  mind  at  all  times. 

One  would  naturally  expect  that  in  inflammation  of  the  corporeal 
endometrium  the  function  of  the  membrane  would  certainly  be  de^l 
ranged,  and  such  is  the  fact.  The  catamenial  discharge  may  be  pro- 
fuse, scanty,  irregular,  and  attended  with  pain,  or  the  function  may 
be  suppressed  altogether ;  the  rule  is,  however,  that  profuse,  pro* 
longed,  and  painful  menstruation  is  present.  "When  cither  of  these 
menstrual  derangements  occurs,  and  there  is  no  constitutional  or  other 
local  cause  to  account  for  it,  we  may  reasonably  infer  that  the  mifr' 
cous  membrane  of  the  uterus  is  at  fault. 

It  may  appear  strange  that  opposite  conditions,  like  menorrhagia 


CORPOEEAL  ENDOMETRITIS.  205 

iind  amenorrhoea,  should  occur  in  the  same  affection  ;  but  tliis  is  ac- 
lounted  for  by  the  condition  of  the  mucous  membrane  in  tlie  differ- 
;nt  stao^es  of  the  disease.  The  same  pecuHarities  of  behavior  are 
loticed  in  inflammation  of  other  mucous  membranes ;  for  example, 
1  n  bronchitis  the  membrane  at  first  may  be  unduly  dry,  and  at  an- 
1  )ther  stage  of  the  disease  there  may  be  a  profuse  secretion.  In  ad- 
;  lition  to  these  changes,  in  the  menstrual  function  there  usually  is 
I  narked  backache,  not  different  in  character,  but  being  more  severe 
i;han  in  cervical  affections.  There  is  also  more  pain  in  the  uterus, 
(pelvic  tenesmus,  vesical  and  rectal  irritation.  Leucorrhoea  is  a 
j  marked  symptom  also.  The  character  of  the  discharge,  as  already 
jdoticed,  is  more  serous,  less  tenacious,  and  more  frequently  contains 
!i  few  blood-  and  pus-corpuscles.  When  cervical  and  corporeal  endo- 
metritis occur  together,  the  discharge  shows  the  characteristics  of 
both  affections. 

Physical  Signs. — The  physical  signs  of  endometritis  are  the 
same  in  character  as  those  indicative  of  inflammation  elsewhere. 
I  There  is  tenderness  detected  by  the  bimanual  touch,  which  usually 
'shows  that  the  body  of  the  organ  is  sensitive.  By  passing  the 
Isound,  the  location  of  tenderness  may  be  exactly  located.  There  is 
I  also  some  enlargement  of  the  cavity  of  the  uterus,  and  the  os  exter- 
num is  dilated.  The  membrane  bleeds  more  readily  on  touch  than 
lit  should.  This  may  be  stated  more  clearly  as  follows  :  By  the  use 
jof  the  sound  four  indications  of  the  disease  can  be  obtained.  First, 
I  the  abnormal  tenderness  ;  next,  the  enlargement  of  the  uterine  cavity, 
i  as  detected  by  actual  measurement ;  then,  dilation  of  the  os  externum ; 
land,  finally,  the  great  vascularity  of  the  membrane,  as  shown  by 
bleeding  on  touch. 

In  using  the  sound  for  diagnostic  purposes  in  coi-poreal  endome- 
tritis, much  skill  and  practice  are  necessary  in  order  to  make  the  ex- 
[amination  with  advantage  to  the  diagnostician  and  safety  to  the 
patient.  Moreover,  care  should  be  taken  to  make  a  disinfectant  ap- 
[  plication  before  using  the  sound,  and  to  be  sure  that  the  sound  itself 
lis  thoroughly  aseptic.  Many  of  the  difficulties  following  the  use  of 
j  the  sound,  related  in  the  books,  I  believe  to  be  due  to  lack  of  care 
and  attention  to  these  points,  thus  permitting  the  carrying  of  septic 
material  into  the  uterus. 

The  density  of  the  uterine  tissues  is  a  valuable  sign  in  determin- 
ing the  existence  of  endometritis.  As  a  rule,  the  body  of  the  uterus 
is  less  dense  than  normal,  excepting  in  cases  of  long  standing,  in 
which  there  is  sometimes  induration  or  hardening  of  the  uterus. 

Prognosis. — Corporeal  endometritis  is  more  difficult  to  manage 


206  DISEASES  OF   WOME}^, 

than  cervical,  and  hsnce  this  has  led  many  of  the  writers  in  the  past 
to  state  tluit  the  affection  is  incurable  in  many  cases.  At  the  present 
time  1  beUeve  that  a  more  favorable  view  of  the  matter  may  be  taken. 
The  disease  in  itself  is  not  dangerous  to  life,  and,  when  uncomj>li- 
cated,  will  usually  yield  to  appropriate  treatment.  There  is  a  decided 
tendency  in  many  cases  for  it  to  return,  but  even  then  it  can  be  re- 
lieved by  removing  the  cause.  The  most  obstinate  cases,  and  also 
those  that  are  neglected,  recover  at  the  menopause. 

The  affection  is  not  in  itself  self-limited,  but  is  limited  by  the 
period  of  functional  activity  of  the  uterus.  There  is  a  prevaihng 
opinion  that  endometritis,  when  it  continues  up  to  the  menopause, 
complicates  "  the  change  of  life,"  and  favors  the  development  of 
malignant  disease.     The  former  opinion  is  true,  the  latter  doubtful. 

The  results  vary  with  the  different  kinds  of  treatment  used.  I 
have  never  seen  a  case  cured  by  certain  methods,  which  have  been 
commended  to  the  exclusion  of  all  others ;  for  example,  hot- water 
douching,  and  the  application  of  the  tincture  of  iodine  to  the 
vagina. 

Neither  does  endometritis  yield  to  treatment  so  long  as  there  % 
a  displacement  of  the  uterus,  or  a  laceration  of  the  cervix ;  but,  when 
all  the  conditions  necessary  to  recovery  are  secured,  then  endometritis 
will  yield  to  local  treatment  in  the  vast  majority  of  cases. 

Causation. — The  causes  of  corporeal  endometritis  have  been  re- 
ferred to  in  discussing  cervical  endometntis ;  hence,  to  save  repe- 
tition, it  will  suffice  to  say  that  there  are  certain  conditions  of  the 
general  system  which  predispose  to  the  affection.  The  strumous 
diathesis,  imperfect  general  nutrition  from  either  gross  living  and 
sedentary  habits,  or  exhaustion  from  overtaxation,  are  tlje  chief  pre- 
disposing conditions. 

The  direct  or  exciting  causes  are  complicated  labors,  miscarriages, 
derangement  of  menstruation,  and  sepsis. 

The  vast  majority  of  cases  of  corporeal  endometritis,  which  have 
come  under  my  observation,  were  clearly  due  to  the  causes  given 
above.  In  fact,  if  those  caused  by  gonorrhea  are  excluded,  nearly 
all  the  others  can  be  ascribed  to  lesions  of  parturition  and  derange- 
ment of  menstruation,  which  arrest  the  post-partum  and  post-men- 
strual involution. 

Treatment. — The  constitutional  treatment  of  inflammatory  dis- 
eases of  the  uterus  was  briefly  referred  to  while  discussing  the  treat- 
ment of  cervical  endometritis,  so  that  it  is  only  necessary  to  repeat 
the  general  statement,  that  every  means  should  be  employed  to  re- 
store the  general  health.    The  treatment  must,  as  a  matter  of  course, 


k 


CORPOREAL  ENDOMETRITIS.  207 

be  adapted  to  tlie  nature  and  degree  of  the  impaired  state  of  the 
a-eneral  organization  in  the  given  case. 

The  local  treatment,  such  as  the  hot-water  douche,  already  de- 
scribed, applies  in  part  to  cervical  endometritis,  and  therefore  need 
not  be  repeated  here.  It  will  suffice  to  give  directions  regarding 
topical  applications  to  the  corporeal  mucous  membrane. 

I  will  first  consider  the  indications  for  intra-uterine  medication, 
the  remedies  to  be  used,  and  the  means  of  employing  them.  This 
question  is  still  with  many  an  unsettled  one,  both  as  regards  the 
I  curability  of  corporeal  endometritis,  and  the  value  and  safety  of 
I  intra-uterine  medication.  The  literature  on  the  subject  of  intra- 
I uterine  treatment  is  not  very  definite,  hence  I  shall  confine  myself 
I  to  a  few  points,  which  I  regard  as  fairly  well  established,  and  likely 
to  be  of  service  in  the  treatment  of  this  disease. 

The  important  questions  which  come  up  for  consideration  on  this 
subject  are,  first,  is  it  safe  and  advantageous  to  make  intra-uterine 
applications  ?  Second,  if  so,  what  curative  agents  shall  be  employed ; 
and,  third,  how  shall  they  be  applied  ? 

Turning  to  the  text-books  or  the  current  literature  on  the  sub- 
ject in  search  of  an  answer  to  the  first  question,  I  find  the  greatest 
diversity  of  opinions. 

The  pioneer  gynecologists  of  Europe,  such  as  M.  Gendriri,  M. 
Jobert  de  Lamballe,  Bennet,  and  Simpson,  rarely,  if  ever,  made  ap- 
plications beyond  the  os  internum,  believing  that  endometritis  could 
be  cured  by  treating  the  cervix  and  the  cervical  canaL  On  the  other 
I  hand,  we  find  that  Aran,  Scanzoni,  and  Gantillon,  and  Dr.  Henry 
•  Miller  (who,  by  the  way,  was  the  first  to  employ  intra-uterine  medi- 
cation in  this  country),  Kammerer,  Nott,  Peaslee,  and  many  others, 
relied  to  a  very  great  extent  on  intra-uterine  applications  for  the 
relief  of  corporeal  endometritis. 

Many  more  names  might  be  mentioned  to  show  the  want  of  har- 
mony among  physicians  on  this  point,  but  no  useful  knowledge 
would  be  gained  thereby.  All  that  can  be  learned  from  a  review  of 
the  literature  is  that  intra-uterine  medication  is  more  extensively 
employed  now  than  formerly.  Believing  that  time  tends  to  drift 
the  profession  to  the  side  of  correct  therapeutics,  it  may  be  inferred 
that  local  applications  to  a  part  or  to  the  whole  of  the  lining  mem- 
brane of  the  uterine  cavity  are  sometimes  necessary,  if  not  indispen- 
sable, in  treating  endometritis. 

In  seeking  an  answer  to  the  second  question,  one  encounters  a 
'variety  of  medicinal  agents,  ranging  from  the  actual  cautery  to  the 
blandest  anodynes. 


208  DISEASES   OF   WOMEN. 

liearing  in  mind,  however,  tlie  second  object  to  be  gained,  name- 
ly, to  restore  the  organ  to  health,  and  leave  it  uninjured,  it  is  evident 
that  all  destructive  agents  should  be  avoided. 

This  has  already  been  stated  in  discussing  the  treatment  of  cer- 
vical endometritis,  and  all  that  was  then  said  ap])lies  with  greater 
force  in  regard  to  corporeal  endometritis,  because  that  portion  of  tlie 
mucous  membrane  is  more  delicate  in  structure. 

In  my  own  practice  I  employ  either  bichloride  of  mercurv,  one 
grain  to  an  ounce  of  water ;  tincture  of  iodine ;  tincture  of  iodine, 
two  parts,  and  carbolic  acid,  one  part ;  or  suppositories  of  iodoform 
and  cocoa-butter. 

There  is  so  much  risk  in  treating  the  mucous  membrane  of  the 
cavity  of  the  body  of  the  uterus  that  there  are  certain  precautions 
which  should  be  kept  in  mind.  These  may  be  formulated  as  follows : 
That  intra-uterine  applications  exciting  to  the  cervical  canal  should 
not  be  used  until  other  means  have  been  thoroughly  tried  and  have 
failed.  The  uterus  should  be  in  or  near  its  normal  position.  The 
cervix  uteri  should  be  sufficiently  dilated  to  allow  any  excess  of  the 
fluid  to  escape  from  the  cavity  of  the  body. 

After  having  carefully  freed  the  cervical  canal  from  the  secretion, 
the  easiest  and  most  effectual  way  of  making  applications  is  to  use 
the  glass  pipette,  already  described. 

The  solution  to  be  employed  is  drawn  up  into  the  glass  tube  by 
the  rubber  bulb ;  the  instrument  is  then  passed  up  to  the  os  inter- 
num or  to  the  fundus  uteri,  if  desired,  and,  as  it  is  withdrawn,  press- 
ure is  to  be  made  upon  the  bulb  whieli  forces  out  the  solution  and 
brings  it  in  contact  ^^ith  the  entire  lining  of  the  canal. 

The  method  generally  in  use  of  dipping  a  probe  wrapped  with 
cotton  into  the  solution,  and  passing  that  u])  into  the  canal,  is  very 
unsatisfactory.  The  cotton  on  the  probe  injures  the  mucous  mem- 
brane, and  the  solution  is  deposited  about  the  os  externum — very 
little,  if  any,  getting  into  the  canal. 

The  injections  by  means  of  a  syringe  and  a  reflux  catheter,  com- 
mended by  many,  I  have  tried,  but  I  have  abandoned  the  method 
because  it  is  dangerous  and  unnecessary. 

It  is  well  to  use  some  bland  fluid,  such  as  warm  water  and  salt, 
to  test  the  toleration  of  the  uterus  before  using  the  more  potential 
agents.  A  small  quantity  of  the  agent  used  is  all  that  is  necessary. 
Six  to  ten  drops  is  sufticient  to  cover  the  surface  to  be  treated,  and 
more  than  that  is  useless. 

When  from  long-continued  congestion  the  mucous  membrane  of 
the  cavity  of  the  uterus  has  become  h}i)ertrophied,  giving  rise  to 


CORPOREAL  ENDOMETRITIS.  209 

tliat  eoiulition  now  known  as  endometritis  poljposa,  the  use  of  the 
I  curette  "-ives  the  most  prompt  relief.     The  blunt  instrument  should 
I  always  be  used,  because  it  is  perfectly  effective  and  free  from  dan- 
i  rt-er.     Dilatation  of  the  cervix  with  tents,  as  a  preliminary  to  the  use 
I  of  the  curette,  should  be  avoided.     No  such  dilatation  is  needed,  as 
a  rule.     When  the  mucous  membrane  is  hypertrophied,  the  canal  of 
I  the  cervix  is  usually  sufficiently  dilated  to  admit  a  curette  large 
[  enough  to  do  the  work.     By  carefully  adhering  to  this  rule  of  prac- 
tice the  pain  and  danger  from  the  use  of  tents  are  avoided,  which 
are  great  advantages  to  the  patient. 

In  the  great  majority  of  cases  of  corporeal  endometritis  with 
thickening  of  the  mucous  membrane,  the  use  of  the  curette  gives 
prompt  and  permanent  rehef ;  still,  there  are  some  which  may  re- 
quire to  be  followed  up  with  other  local  treatment,  such  as  has  been 
described. 

ILLUSTRATIVE   CASES. 

This  patient  w^as  thirty-two  years  of  age,  had  been  manied  ten 
years,  and  had  two  children.  After  the  birth  of  the  iirst  child  she 
was  quite  well  for  two  years,  and  then  she  again  became  pregnant, 
and  miscarried  at  three  and  a  half  months.  After  this  she  had  a 
slight  leucorrhoea  for  a  time,  with  other  evidence  of  uterine  disease, 
but  she  appeared  to  have  recovered  from  this,  and  gave  birth  to  an- 
other child. 

She  made  a  good  recovery  from  her  confinement,  and  nursed  her 
child  for  about  six  months.  Her  health  then  began  to  fail,  and  she 
weaned  the  child. 

Two  months  after  this  the  menses  returned,  and  at  the  time  were 
quite  scanty,  and  only  lasted  for  a  day  or  two.  She  attributed  this  to 
over-exercise  during  a  journey  which  she  had  taken,  not  expecting  to 
be  unwell.  After  this  she  suffered  from  backache,  pelvic  tenesmus, 
and  irritable  bladder,  with  free  leucorrhoea,  at  first  like  an  ordinary 
cervical  secretion  in  character.  Her  general  condition  also  became 
largely  disordered.  The  appetite  was  capricious ;  the  bowels  con- 
stipated and  distended  from  flatulence ;  she  also  had  occasional  at- 
tacks of  nausea,  and  at  times  headache ;  she  became  quite  nervous, 
and  her  sleep  was  broken  and  disturbed ;  the  backache  and  peh-ic 
pain  and  tenesmus  were  such  that  she  could  only  stand  or  walk  for 
a  short  time.  She  also  had  pain  in  the  pelvis,  which  radiated  through 
the  abdomen  ;  her  menstruation  became  irregular,  generally  coming 
on  at  the  end  of  two  or  three  weeks  and  continuing  longer  than 
normal,  and  was  too  free,  and  during  the  year  pre^^ous  to  my  seeing 
her  had  at  times  been  offensive  ;  between  the  menstrual  periods  the 
15 


210  DISEASES  OF   WOMEN". 

discharge  was  of  a  mixed  cliaracter,  composed  of  cervical  leucorrlioea 
stained  with  blood  and  mixed  with  serum,  and  oecasionallv  traces  oj 
pus,  which  was  then  slightly  offensive.  She  complained  at  time 
also  of  pruritus  of  tlie  vulva.  Wiien  first  examined  I  found  tli 
uterus  larger  tlian  normal,  the  increase  in  size  being  mostly  of  tin 
body  and  fundus.  Bimanual  pressure  being  made  upon  the  body  <ji 
the  uterus  gave  rise  to  a  dull  pain.  A  speculum  examination  re 
vealed  considerable  redness  around  the  os  externum,  but  no  great 
enlargement  of  the  raucous  membrane  of  the  cervix,  and  very  little 
if  any,  eversion.  The  discharge,  as  seen  coming  from  the  canal,  w;i 
dark  in  color,  as  if  stained  and  streaked  with  blood ;  around  this  ti 
nacious  material  there  was  a  little  sero-purulent  discharge  noticeable 
Upon  introducing  the  sound  the  canal  of  the  cervix  was  found  to  h 
somewhat  dilated,  and  the  os  internum  was  largely  so.  The  sound 
entered  two  and  a  half  inches,  and  could  be  moved  about  considera 
bly  in  the  cavitv  of  the  bodv,  showino;  that  the  cavitv  was  enlar<^ed 
Gently  touching  the  fundus  and  sides  of  the  utcnis  with  the  soun< 
gave  rise  to  pain,  and  the  patient  complained  of  a  little  nausea  an^ 
faintness ;  from  the  general  history  and  the  physical  signs  the  diag 
nosis  of  inflammation,  involving  the  entire  mucous  membrane  of  tin 
uterus,  was  made.  At  this  time  the  patient's  tongue  was  coated.  an( 
her  appetite  poor.  As  she  was  constipated  she  was  given  a  d»»se  o1 
blue  mass,  with  ipecac,  that  night,  followed  by  a  Seidlitz  powder  ii 
the  morning;  and  after  this  a  bitter  tonic  of  Colombo  and  wine  ol 
ipecac  before  her  meals,  and  a  teaspoonful  of  Parish's  com}),  sirup  ol 
phosphates  after  meals. 

From  this  time  onward  the  constitutional  treatment  consists' 
simply  of  iron  tonics  in  succession,  as  follows:  Citrate  of  iron  au' 
quinine,  the  sirup  of  the  iodide  of  iron,  pyrophosphate  of  iron,  and 
bitter  wine  of  iron,  with  very  small  doses  of  strychnia.  The  bosvel- 
were  kept  regular  Ijy  a  laxative  pill,  and  she  was  ordered  to  taki 
plenty  of  nourishing  food.  At  first  she  was  allowed  to  take  ver\ 
little  exercise — in  fact,  not  any  for  the  first  two  weeks ;  under  thi- 
treatment  her  general  condition  improved,  and  the  local  treatment 
consisted  in  first  removing  the  secretion  from  the  cervix,  and  then 
applying  carbolic  acid  and  iodine.  She  was  then  directed  to  take  n 
hot-water  douche  night  and  morning  regularly.  The  local  appli- 
cation caused  pain  for  several  hours,  and  did  not  appear  to  do  an\ 
good.  At  the  end  of  the  week  I  passed  a  medium-sized  curette  int- 
the  uterus,  and  gently  curetted  the  entire  mucous  membrane  of  tin 
body  ;  this  brought  away  considerable  serum  and  blood,  some  ol 
which,  from  its  dark  color,  had  evidently  been  retained  for  some 


CORPOREAL  ENDOMETRITIS.  211 

time.  There  was  also  mueo-purnlent  looking  material  wliicli  came 
away  at  the  same  time,  but  this  may  have  come  from  the  cervix. 
Oil  carefully  examining  all  that  was  removed  from  the  uterus,  sev- 
eral little  masses  of  fungous  material,  about  the  size  of  the  head  of  a 
laro-e  pin,  were  found,  and  several  shreds  that  looked  like  poi'tions 
of  the  epithelial  layer  of  a  thickened  and  softened  membrane. 

The  curetting  seemed  to  be  a  failure,  so  far  as  obtaining  any 
large-sized  fungosities  which  I  had  been  led  to  suspect  existed  fi'om 
the  frequent  and  profuse  menstruation.  Considerable  pain  was 
caused  by  the  use  of  the  curette,  and  it  lasted  for  several  hours,  but 
finally  passed  away.  The  patient  also  complained  of  being  faint  and 
having  nausea,  and,  as  she  appeared  pale  after  the  operation,  I  have 
no  doubt  that  her  suffering  was  very  great,  though  she  was  a  brave 
lady,  and  did  not  com23lain  without  cause.  There  was  considerable 
oozing  of  bloody  serum  from  the  uterus  for  two  days  after  the  cu- 
retting. About  live  days  afterward  an  examination  revealed  a  copi- 
ous discharge  of  cervical  secretion,  which  was  rather  dark  in  color 
and  slightly  yellow,  as  if  it  contained  j)us.  Very  small  clots  of 
blood  were  also  found  entangled  in  it.  The  cervix  was  then  freed 
from  the  secretion,  and  iodine  and  carbolic  acid  again  applied.  The 
next  menstrual  How  came  on  at  the  proper  time  and  was  quite  free, 
but  it  did  not  last  quite  as  long  as  usual.  Two  days  after  the  flow 
had  subsided  I  again  used  the  curette,  with  the  result  of  bringing 
away  some  blood  and  muco-serous  material,  but  no  slireds  of  mem- 
brane nor  fungosities.  The  patient  suffered  much  less  this  time 
from  the  treatment.  From  this  onward,  once  a  week,  a  pencil  made 
of  cocoa-butter,  and  as  much  iodoform  as  the  butter  would  take  up 
(about  four  grains  in  all),  was  passed  up  into  the  cavity  of  the  uterus 
as  near  to  the  fundus  as  possible ;  carbolic  acid  and  iodine  were  ap- 
plied to  the  cervical  canal.  This  treatment  seeming  effectual,  and 
the  patient  improving,  it  was  repeated  once  a  week  for  about  two 
months ;  during  this  time  the  uterus  diminished  in  size,  the  discharge 
also  became  less,  and  changed  to  the  character  of  that  usually  found 
in  cervical  endometritis.  The  menstruation  then  became  regular  as 
to  time  and  less  profuse,  and  did  not  last  longer  than  the  usual  time. 
The  intra-utcrine  applications  were  then  suspended,  except  the  appli- 
cation of  iodine  and  carbolic  acid,  which  was  continued  once  a  week 
to  the  cervical  canal  for  alwut  two  months  longer.  She  had  then 
I  improved  so  much  in  her  general  condition,  and  the  utenis  appear- 
I  ing  to  be  normal,  except  that  she  still  had  slight  cervical  leucorrhoea, 
I  unwisely  told  her  that  she  was  quite  well,  and  she  did  not  return 
lur  any  after-treatment  for  six  months.     Her  leucorrhoea  at  this  time 


212  DISEASES  OF   WOMEN. 

became  again  rather  troublesome,  and  she  came  back  for  further 
care.  I  then  found  that  her  general  condition  wius  entirely  wti*- 
factory ;  her  mensti-ual  flow  was  regular  and  normal ;  the  internal  og 
had  contracted  to  its  natural  size;  the  uterus  measured  three  iiicheg 
only  in  its  longest  diameter,  and  all  that  remained  of  the  former 
trouble  was  a  hjperaemic  state  of  the  cervical  mucous  membrane, 
with  Icucorrhcea ;  this  was  treated  for  about  six  weeks  with  one  part 
of  carbolic  acid  to  three  of  iodine,  and  then  she  was  dismissed  jkt- 
fectlj  M'ell. 

I  have  been  informed  that  she  has  given  birth  to  a  child  siiice 
she  was  under  my  care. 

Chronic  Corporeal  Endometritis. — The  patient  was  twenty-nine 
years  old,  and  had  one  child  when  twenty-three,  and  a  miscarriage 
when  twenty-five  years  of  age.  Up  to  the  time  of  her  mi.searrijige 
her  health  had  been  very  good,  but  from  this  time  she  began  to 
suffer. 

The  menses,  formerly  normal,  began  to  be  too  free,  and  were 
attended  with  pain.  In  fact,  from  the  time  of  the  miscarriage  she 
had  menorrhagia  and  dysmenorrhoea,  and  both  became  more  marked 
as  time  went  on.  The  pain  in  the  uterus  at  the  time  of  the  menses 
was  not  acute,  but  was  continuous  and  aching.  It  began  a  day  or 
two  before  the  flow  and  continued  until  the  flow  ceased,  and  some- 
times for  several  days  after.  There  was  some  irregularity  about  the 
recurrence  and  quantity  of  the  menses,  and  she  observed  that  when 
the  flow  was  very  free  the  pain  was  not  so  severe.  At  some  of  the 
menstnial  periods  tlie  flow  would  begin  and  go  on  for  a  day  and 
then  stop  for  hours,  and  then  come  on  again  quite  freely.  When 
these  interruptions  took  place  there  usually  were  clots  passed,  which 
evidently  came  from  the  uterus,  because  they  were  ex})elled  after 
pains  which  differed  from  the  usual  ]xiin  in  being  more  acute  and 
inteiTiiittent. 

Tlie  menorrhagia  and  dysmenorrhoea  became  gradually  worse, 
the  pain  being  greater  when  the  flow  was  less.  She  became  nmch 
exhausted  at  each  period,  either  from  pain,  loss  of  blood,  or  both. 
Throughout  the  whole  course  of  the  affection  she  had  a  discharge 
from  the  utenis  which  was  sero-purulent. 

At  times,  especially  before  the  menstrual  period,  there  was  a  cer- 
vical leucorrhoea,  but  the  discharge  from  the  l)ody  of  the  uterus  was 
most  marked  and  continuous.  It  was  more  yellowish  in  color,  Icfifl 
tenacious  than  cervical  leucorrhrea  usually  is,  and  oftentimes  it  was 
tinged  with  blood  and  quite  offensive  in  O'lor. 

There  was  much  backache,  pain   in  the  pelvis,  and  wandering 


CORPOREAL  ENDOMETRITIS.  213 

nains  in  the  abdomen.     Tlie  apj)etite  was  capricious;  at  times  fairly 

<i;()od,  and  at  other  times  very  poor.     She  often  had  nausea,  which 

lasted  for  a  short  time.     Tlic  bowels  were  constipated,  and  she  was 

[  greatly  tormented  with  flatulence.    Her  ultimate  nutrition  was  poor; 

I  she  had  lost  flesh,  and  on  her  face  there  were  many  large  blotches. 

The  nervous  system  was  very  considerably  disturbed.    Originally 

(»f  a  cheerful  disposition,  she  became  irritable  and  emotional.     Sleep 

!  jl  was  often  broken  at  night,  and  she  had  unpleasant  dreams.     During 

I  the  day,  especially  after  eating,  she  became  drowsy,  but  seldom  could 

1  sleep,  if  she  tried  to  do  so.     In  other  words,  she  was  ansemic  and 

neurasthenic. 

She  suffered  at  times  from  a  spasmodic  cough,  due  evidently  to 
deranged  innervation.  There  was  no  organic  disea  e  of  the  lungs  or 
bronchi.  The  general  treatment  was  tonic  and  sedative.  Mild  lax- 
atives were  also  given.  Locally,  the  hot-water  douche  w^as  used, 
and  equal  parts  of  iodine  and  carbolic  acid  were  applied  to  the  cervix. 
This  did  not  give  any  relief  to  the  local  symptoms,  and  her  general 
condition  improved  very  little.  The  menstrual  flow  was  as  free  and 
painful  as  before. 

The  curette  was  used,  and  some  fungous  material  removed  ;  after 
this  she  felt  better,  and  the  menstrual  flow  was  more  natural.  Sub- 
sequently she  neglected  her  treatment,  and  in  a  few  months  all  the 
old  symptoms  returned. 

The  curette  was  used  again,  and  a  larger  quantity  of  fungous 
material  removed  ;  after  this,  one  part  carbolic  acid  and  two  of  tinct- 
ure of  iodine  were  applied  to  the  whole  cavity  of  the  uterus,  once  a 
week — three  such  applications  being  made  during  the  inter-menstraal 
periods. 

The  applications  caused  pain,  which  compelled  her  to  rest  in  bed 
during  the  day  on  which  they  were  made.  The  constitutional  treat- 
ment was  kept  up,  and  the  local  applications  were  continued  for  a 
period  of  three  months.  After  this  an  application  was  made  after 
each  menstruation  for  three  months. 

In  all,  her  treatment  extended  over  a  period  of  several  months. 
She  was  then  quite  well  in  general  health,  and  her  menstruation  was 
regular  and  normal. 

It  is  now  eight  years  since  she  recovered  her  health,  and  she  is 
quite  well. 


CHAPTER   XL 

SUBmVOLUTION. 

Subinvolution  of  the  Uterus  after  Parturition.  —  Tlie  great  in- 
crease in  the  size  of  tlie  uterus  during  gestation,  and  its  raj^id  reduc- 
tion after  delivery,  are  among  the  most  remarkable  plienomena  iu 
the  animal  economj. 

The  uterus  during  nine  months  increases  from  about  two  ounces 
to  two  pounds  in  M'eight  during  the  evolution  of  gestation,  and  it  is 
reduced  by  involution  in  the  short  space  of  two  or  three  weeks. 
This  process  of  involution  (by  w]iich  the  uterus  is  reduced  to  its 
original  size)  is  a  transformation  and  absorption  of  the  tissues.  The 
structural  elements  of  the  uterus,  w^liich  are  no  longer  needed,  un- 
dergo fatty  degeneration  and  absorption,  and  are  in  that  way  dis- 
posed of. 

The  time  recpiired  for  this  involution  to  take  place,  and  the 
causes  which  may  interrupt  it,  have  been  clearly  pointed  out  by  Dr. 
Alexander  Sinclair,  of  Boston,  in  vol.  iv  of  the  "■  Transactions  of  the 
American  Gynecological  Society,"  1879.  Dr.  Sinclair  gives  the  re- 
sults of  careful  measurements  of  the  uterus  in  one  hundred  and  eight 
cases.  These  measurements  were  made  from  twelve  to  thiity-six 
days  after  delivery,  the  average  being  sixteen  days.  In  the  great 
majority  of  these  cases  the  uterus  had  been  reduced  to  its  normal 
size  at  the  end  of  three  weeks.  In  one  the  uterus  measured  two  and 
one  half  inches  on  the  twelfth  day.  This  shows  the  wonderful  ra- 
pidity with  which  this  involution  goes  on. 

In  all  the  cases  in  which  the  involution  was  retarded,  there  were 
present  certain  morbid  states,  such  as  laceration  of  the  ])erina3um  or 
cervix  uteri,  metritis,  or  septicaemia. 

These  observations  of  Dr.  Sinclairs  are  of  the  highest  value  in 
showing  the  time  required  for  the  process  of  involution,  and  also  the 
conditions  which  interrupt,  retard,  or  arrest  it. 

Pathology. — In  uncomplicated  cases  there  are  no  inflammatory 


SUBINVOLUTION.  215 

products,  nor  are  there  any  new  tissue  formations.  The  structures 
of  the  uterus  are  the  same  as  hi  the  normal  state,  but  developed  by 
gestation.  In  ,Dr„  Snow  Heck's  case  the  microscopical  appearances 
were  hke  those  found  in  the  middle  period  of  utero-gestation.  In 
other  cases  evidences  of  fatty  degeneration  have  been  observed  in 
the  nniscular  tissues. 

AVhen  the  involution  has  been  arrested  by  puerperal  metritis,  the 
products  of  the  inflammation  are  found.  According  to  Dr.  Noeg- 
geratli,  those  products  are  inflammatory  exudations  and  hyperplasia 
of  the  cells  of  the  areolar  tissue. 

Symptomatology. — I  have  never  observed  any  symptoms  which 
were  specially  characteristic  of  imperfect  involution.  The  history 
of  the  delivery  and  subsequent  progress  usually  presents  Some  fact 
which  would  suggest  possible  subinvolution. 

There  are  usually  present  leucorrhoea  and  backache,  and  pelvic 
tenesnnis  upon  standing  or  walking,  but  all  these  symptoms  occur  in 
other  aifections. 

Physical  Signs. — Digital  examination  shows  that  the  uterus  is 
enlarged  and  softer  than  normal.  Very  often  it  is  low  down  in  the 
pelvis.  The  vagina  also  is  found  to  be  enlarged  and  relaxed.  The 
rule  is  that  if  involution  is  arrested  in  the  uterus  it  is  also  arrested 
in  the  vagina  and  in  the  uterine  ligaments.  There  are  many  ex- 
ceptions to  this  rule,  however ;  as,  for  example,  a  laceration  of  the 
cervix  uteri  and  perineeum  will  arrest  involution  of  the  cervix  and 
vagina,  while  the  body  of  the  uterus  may  return  through  involution 
to  its  normal  size. 

This  can  be  made  out  easily  by  the  touch  in  most  cases.  The 
sound,  used  through  the  speculum,  shows  the  exact  size  of  the  uterus, 
and  when  that  abnormal  size  occurs  after  confinement,  and  is  not 
otherwise  accounted  for,  it  is  a  reliable  sign  of  subinvolution.  The 
cer\nx  and  vagina  are  usually  of  a  deep,  bluish-red  color,  and  there 
is  dilatation  of  the  cervical  canal,  and  usually  some  eversion  of  the 
lips  of  the  OS  externum. 

Prognosis. — Recovery  may  be  expected  under  proper  care  if 
treatment  is  begun  early  and  can  be  fully  carried  out,  and  there  are 
no  complications  which  can  not  be  removed.  In  case  that  the  tissues 
are  damaged  by  metritis  the  case  may  go  on  to  sclerosis,  and  become 
incurable.  When  the  subinvolution  is  due  to  injuries  of  the  cervix, 
the  restoration  of  the  injured  parts  is  usually  followed  by  a  comple- 
tion of  the  involution. 

Cassation. — Injuries,  such  as  laceration  of  the  cervix  and  peri- 
niKum,  and  septic  infection  causing  either  cellulitis,  hanphangitis,  or 


216  DISEASES  OF  WOMEN. 

metritis,  are  the  chief  causes.  Getting  up  too  early  after  confine- 
ment, and  engaging  in  hard  work  in  the  erect  position,  are  also  liahle 
to  arrest  this  process.  All  the  cases  that  I  have  seen  were  traced  to 
some  of  the  ahove-nanied  causes. 

Treatment. — Tlie  management  of  subinvolution  usually  falls  to 
the  obstetrician  in  case  he  is  on  the  watch  for  it.  AVhen  not  com- 
plicated with  any  well-defined  puerperal  affection  it  is  apt  to  ])as8  for 
a  time  unnoticed,  because  it  does  not  give  rise  to  suffering  until  the 
patient  is  about  her  duties  again. 

When  the  patient  begins  to  go  about  after  her  confinement,  and 
there  is  pelvic  tenesmus,  backache,  and  leucorrhoea,  imj)erfect  invo- 
lution should  be  suspected  ;  and,  if  the  physical  signs  confirm  the 
diagnosis,  the  patient  should  be  put  back  to  bed,  and  kept  there  for 
a  time.  If  the  recumbent  posture  is  not  sufficient  to  restore  the 
uterus  to  its  normal  position,  artificial  support  should  be  used,  either 
by  pessary  or  tampon.  The  hot-water  douche  should  be  employed, 
and  if  there  is  imperfect  involution  of  the  vagina  and  pelvic  floor, 
tannin  or  sulphate  of  zinc  may  be  occasionally  added  to  the  douche. 

In  the  past,  antiphlogistic  measures  were  employed  as  the  chief 
treatment.  Leeches  were  applied  to  the  cervix,  and  puncturing  and 
scarifying  were  employed  to  abstract  blood  from  the  uterus.  Thia 
depletion  is  doubtless  beneficial  when  there  is  well-marked  engorge- 
ment, and  the  general  state  of  the  patient  is  good — not  anaemic,  as  is 
generally  the  case  with  these  patients. 

Local  bloodletting  should  not  be  employed  unless  there  is  extreme 
congestion,  neither  should  it  l)e  repeated  more  than  once  or  twice. 
A  certain  degree  of  hypernemia  is  necessary  to  the  process  of  involu- 
tion, and  anaemia  will  arrest  the  process.  Depletion  is  only  admissi- 
ble in  morbid  hyperaemia.  That  it  is  useful  in  such  cases  is  beyond 
doubt.  The  value  of  de])letion  is  seen  in  those  who  resume  the  func- 
tion of  menstruation  soon  after  delivery.  A  profuse  menstruation  is 
generally  followed  by  improvement. 

I  have  generally  relied  upon  less  depressing  measures.  AVhile 
taking  care  of  the  general  health,  I  have  advised  rest,  the  hot  douche, 
and  tincture  of  iodine  applied  to  the  cerv^ix,  cervical  canal,  and  upper 
portion  of  the  vagina.  When  -these  have  failed,  I  have  used  elec- 
tricity in  the  same  way  as  in  the  treatment  of  uterine  fibroids,  but 
not  with  so  strong  a  current.  I  believe  that  this  agent  is  one  of  the 
most  valuable  in  the  management  of  subinvolution. 

In  cases  of  long  standing  there  is  usually  some  injury  of  the  cer- 
vix uteri  or  the  pelvic  floor;  when  such  is  the  case,  the  lacerations 
must  be  repaired  before  involution  will  be  completed. 


SUBINVOLUTION.  217 

It  is  almost  needless  t(j  add  that  all  complicating  conditions,  such 
as  endometritis,  should  liave  due  attention. 

Superinvolution  of  the  Uterus  after  Parturition. — This  affection 
was  lirst  described  by  Sii*  James  Y.  Simpson,  and  illustrated  with 
cases  which  occurred  in  his  practice, 

I  presume  it  must  be  a  very  rare  condition.  I  have  not  seen  a 
case  about  the  diagnosis  of  which  I  felt  sure.  Premature  atrophy  of 
the  uterus  I  have  seen,  due  to  destructive  disease  of  the  ovaries,  re- 
moval of  the  ovaries,  and  certain  peculiar  states  in  which  the  meno- 
pause occurred  prematurely,  but  a  case  not  so  accounted  for  has  not 
occurred  in  my  practice.  I  saw  a  patient  once  in  consultation,  six 
months  after  her  confinement,  who  suffered  from  pain  in  the  abdo- 
men, which  was  due  apparently  to  adhesions  from  an  old  peritonitis. 
The  uterus  was  very  small  for  one  who  had  borne  children,  in  fact  it 
was  below  the  size  of  a  virgin  uterus.  The  menses  had  been  scanty„ 
I  made  a  diagnosis  of  superinvolution,  and  gave  the  attending  phy- 
sician a  brief  clinical  lecture  on  the  subject.  He  examined  the  uterus 
afterward,  and  confirmed  my  statement  regarding  the  size  of  it. 
While  I  felt  sure  that  the  pain  present,  and  for  which  I  was  con- 
sulted, was  in  no  way  connected  with  the  small  uterus,  I  took  occasion 
to  say  that  the  patient  would  remain  sterile ;  and  I  also  predicted 
an  eai'ly  menopause.  To  my  surprise  she  gave  birth  to  a  healthy 
child,  of  full  size,  about  one  year  after  I  had  made  the  diagnosis. 

Perhaps  superinvolution,  to  a  certain  extent,  may  not  necessarily 
cause  sterility,  and  my  diagnosis  may  in  this  case  have  been  correct, 
but  I  do  not  believe  so. 

Owing  to  my  lack  of  personal  knowledge  on  this  subject,  I  will 
here  give  in  full  the  case  reported  by  Sir  James  Y.  Simpson,  in  his 
work  on  "Diseases  of  Women"  : 

"  The  subject  of  this  rare  pathological  affection  began  to  men- 
struate at  the  age  of  thirteen,  and  the  catamenia  recurred  regularly 
eveiy  four  weeks  till  she  became  pregnant  when  eighteen  years  old. 
Utero-gestation  went  on  without  any  unusual  phenomena  to  the  full 
term  ;  and  her  parturition  was  natural  but  tedious,  a  male  child  being 
born  after  a  labor  of  seventeen  hours.  I^otliing  unusual  occurred 
during  her  puerperal  convalescence  and  lactation.  But  subsequent 
to  delivery  she  never  menstruated.  She  was,  however,  subject  to 
frequent  attacks  of  diarrhoea,  which  she  herself  believed  to  be  gener- 
ally most  severe  at  recurring  monthly  intervals ;  and  the  dejections 
were  then  sometimes  tinged  with  blood. 

"Two  years  after  aoconchement  she  became  a  patient  in  the  fe- 
male ward  of  the  Koyal  lutirmary,  complaining  of  the  state  of  amenor- 


218  DISEASES   OF   WOMEX. 

rlid^a,  ^vitll  attciKhmt  broken  health.  Slie  suii'ered  i'njiii  jjuin  iu  the 
back  and  liypogastriuiii,  with  a  sensation  of  weight  and  pressure  in 
the  pelvic  region  ;  dysuria ;  a  furred  tongue;  and  a  weak  compressi- 
ble pulse,  generally  beating  from  80  to  l>0  in  the  minute.  She  was 
thin,  feeble,  and  anemic  in  appearance.  The  mammae  were  shrunk 
and  flat.  For  some  time  before  admission  she  had  suffered  niucli 
from  occiusional  headaches  and  giddiness;  frequent  nausea  and  vom- 
iting ;  palpitation  and  occasional  rigors. 

"■  On  making  a  vaginal  examination,  I  found  the  uterus  small  and 
mobile.  The  cervix  uteri  was  much  atrophied,  and  the  vaginal  por- 
tion of  it  scarcely  made  any  projection  into  the  canal  of  the  vagina. 
The  OS  nteri  was  so  much  contracted  as  to  admit  a  surgeon's  probe 
with  ditiiculty.  It  was  dilated  by  a  slender  bougie  being  left  in  for 
two  or  three  days ;  and,  when  the  uterine  sound  was  subsequently 
used,  the  uterine  cavity  was  found  to  be  only  one  and  a  half  inch 
in  length,  or  about  an  inch  less  than  normal. 

"  A  variety  of  means  was  employed  with  the  view  of  beneliting 
the  general  health  of  the  patient,  and  of  exciting  action  in  the  uterine 
system,  but  with  little  or  no  effect. 

''  Diarrhoea  repeatedl}'-  occurred  during  the  three  or  four  weeks 
she  remained  under  my  care,  requiring  the  free  use  of  opiates  for  its 
restraint ;  and  as  the  uterine  symptoms  did  not  at  the  time  seem  to 
admit  of  special  attention  and  treatment,  the  patient  was  transferred 
to  one  of  the  general  wards  of  the  hospital,  where  she  was  placed 
under  the  care  of  my  colleague,  Dr.  Bennett. 

"  Durinsr  the  foUowincj  month  the  diarrhoea  recurred  from  time 
to  time  very  severely.  At  last  anasarca  in  the  lower  extremities  and 
albuminuria  supervened  ;  ascites  followed  ;  and  shortly  afterward  her 
face  and  arms  became  oedematous.  About  a  month  after  these  symjv 
toms  appeared  delirium  at  last  came  on, , the  fa3Ces  passed  involun- 
tarily, and  ultimately  she  died  in  a  state  of  prolonged  coma. 

"  On  post-mortem  inspection  some  crude  tubercles  were  found  iu 
both  lungs,  especially  in  the  left.  The  liver  was  enlarged,  and  showed 
some  fatty  transformation.  The  kidneys  presented  also  some  stearoid 
degeneration,  and  in  the  right  there  was  in  addition  a  small  tubercu- 
lar abscess.  The  large  intestines  were  very  much  thickened  in  their 
parietes,  and  contracted  in  their  caliber,  while  their  mucous  mem- 
brane was  ulcerated  in  various  parts.  Along  the  lower  end  of  the 
ileum  several  large  ulcerations  were  seen  running  circumferentinlly 
around  the  interior  of  the  bowel.  One  or  two  ulcerations  were  also 
found  in  the  stomach.  The  uterus  was  very  small,  and  atrophied  in 
its  length  and  breadth,  its  size  being  diminished  about  a  third  below 


SUBINVOLUTION.  219 

the  natural  standard  in  all  its  incasiircnients,  and  its  parietcs  were 
correspondingly  thin  and  reduced.  The  whole  length  of  the  uterine 
cavity  from  the  os  to  the  fundus  was  not  more  than  one  inch  and  a 
half,  while  the  normal  uterus  usually  measures  in  this  direction  two 
inches  and  a  half.  When  a  section  was  made  of  the  posterior  wall 
of  the  organ,  the  thickness  of  its  parietes  at  their  deepest  or  most 
developed  point  was  not  above  three  lines,  instead  of  the  normal 
measurement  of  live  or  six  lines.  Tlie  tissue  of  the  uterus  a^^peared 
dense  and  fibrous,  and  the  section  of  it  presented  the  orifices  of  nu- 
merous small  vessels.  The  ovaries  seemed  also  much  atrophied,  and 
smaller  than  natural.  Their  tissue  was  dense  and  fibrous,  and  pre- 
sented no  appearance  of  Graafian  vesicles.  There  was  no  inflamma- 
tory deposit  on  the  peritoneal  surface  of  the  uterus  or  its  appendages ; 
but  some  thick  pus,  or  tubercular  matter,  existed  in  the  distended 
cavity  of  the  right  Fallopian  tube." 


CHAPTEK    XII. 

SCLEROSIS    OF    THE    UTERUS. 

Fifteen  years  ago  I  employed  tliis  term  to  designate  an  aflfection 
of  the  uterus,  which  up  to  that  time  had  been  known  by  a  variety  of 
names — such  as  chronic  interstitial  metritis,  hypertrophy,  chronic 
inflammatory  hypertroj^hy,  and  areolar  hyperplasia.  Subsequently 
Gallard  used  the  same  term  in  the  same  way. 

This  affection  of  the  uterus  is  a  change  of  structure  produced  by 
a  pre-existing  inflammation  or  derangement  of  nutrition,  and  may 
be  more  properly  considered  as  the  product  of  morbid  action,  rather 
than  active  disease.  The  term  which  I  have  selected,  therefore, 
more  clearly  indicates  the  tnie  nature  of  the  affection  than  the  names 
of  the  affections  or  processes  which  produce  it,  and  by  which  it  has 
heretofore  been  designated. 

Pathology. — This  comprises  certain  changes  of  stnicture,  mostly 
of  the  middle  coat  of  the  uterus,  which,  as  already  stated,  have  been 
caused  by  preceding  morbid  processes. 

This  chancre  of  structure  consists  in  an  excess  of  connective  tissue, 
the  result  of  an  areolar  hyperplasia.  This  element  in  the  structure 
of  the  uterine  walls  rapidly  increases,  encroaching  upon  the  mus- 
cular element,  and  more  especially  upon  the  blood-vessels  in  the 
connective  tissue.  The  result  is  marked  increase  in  the  density  of 
the  tissue?,  and  an?eraia  from  pressure  upon  the  vessels.  Thore  is 
frequently  an  increase  in  the  size  of  the  whole  organ,  but  in  some 
cases  the  uterus  is  not  enlarged.  In  fact,  the  utenis  may  notably 
dimini?;h  in  size,  when  the  hyperplasia  is  sufficient  to  cause  atrophy 
of  the  other  tissues  of  the  uterus. 

The  histological  composition  of  the  tissues  differs  in  different 
cases,  and  in  different  stages  of  the  development  of  the  affection. 

In  those  cases  which  have  their  genesis  in  puerperal  metritis 
there  is  generally  at  first,  in  addition  to  hyperplasia  of  connective 
tissue,  a  fatty  degeneration  of  the  muscular  tissue,  which  has  not 


SCLEROSIS   OF   THE   UTERUS.  221 

been  disposed  of  by  the  process  of  involution.  There  are,  also,  in 
some  cases,  some  of  the  products  of  the  intlammation  in  the  form  of 
exudation  into  the  tissues.  All  these  give  the  uterus  its  increase  in 
size,  which  to  sonic  extent  is  permanent,  although  the  organ  may 
diminish  very  much  in  time. 

The  hyperplasia  of  the  connective  tissue  causes  atrophy  of  the 
other  tissues,  and  to  that  extent  the  uterus  is  reduced  in  size.  When 
the  sclerosis  follows  non-puerperal  metritis  the  uterus,  which  dur- 
ing the  stage  of  inflammatory  engorgement  was  larger  than  normal, 
may  become  reduced  to,  or  even  below,  its  normal  size.  This  is 
more  likely  to  occur  when  the  hyperplasia  is  extensive,  and  involves 
all  the  tissues  of  the  uterus  and  their  blood-vessels. 

Sclerosis  may  be  general  or  local.  When  due  to  puerperal  or 
chronic  metritis,  or  to  deranged  nutrition  from  long-continued  con- 
gestion, the  whole  organ  shares  in  the  morbid  process.  AMien  it  is 
due  to  some  injury  and  inflammation,  or  deranged  nutrition  of  the 
cervix,  the  body  may  remain  normal.  Circumscribed  patches  of 
sclerosis  in  the  body  or  cervix  have  not  been  found. 

Finally,  this  is  a  permanent  affection.  When  once  the  changes 
of  structure  have  taken  place  they  remain,  to  a  certain  extent  at 
least.  There  is  no  tendency  to  complete  restoration  of  the  normal 
tissue.  There  may  be  a  slight  diminution  of  the  size  of  the  uterus. 
I  am  inclined  to  think  that  even  at  the  menopause,  the  period  at 
which  almost  all  uterine  affections  subside,  this  lingers,  and  possibly 
remains  always. 

I  have  had  an  opportunity  of  observing  several  cases  some  time 
after  the  change  of  life,  and  the  utems  in  all  of  them  was  larger  than 
it  should  be.  Dr.  Xoeggerath  claimed  that  sclerosis,  or  chronic  me- 
tritis, as  he  called  it,  predisposed  to  cancer  of  the  uterus.  This  may 
be  so.  There  is  in  this  affection  a  change  of  structure,  and,  accord- 
ing to  the  rule  in  pathology,  a  consequent  lowering  of  the  vitality 
of  the  part,  and  a  predisposition  to  further  degeneration. 

Symptomatology. — The  clinical  history  of  this  affection  differs  in 
many  points  from  that  of  other  forms  of  uterine  disease,  but  there 
are  no  symptoms  that  are  diagnostic. 

There  is  more  marked  constitutional  disturbance  in  the  pro- 
nounced cases  than  is  found  in  the  average  inflammatory  affections. 
This  may  be  due  largely  to  the  exhausting  effect  of  the  disease  which 
preceded  the  sclerosis — this  being  quite  suflicient  to  keep  up  the 
general  ill-health. 

There  is  derangement  of  menstruation,  usuallv  amenorrhoea.  In 
well-marked  cases  neuralgic  pains  in  the  uterus  are  frequently  pres- 


222  DISEASES  OF  WOMEN. 

ent,  wliicli  arc  imicli  worse  at  the  menstrual  period.  The  pain  at 
this  time  often  begins  before  the  flow  and  continues  throughout  the 
whole  period,  and  sometimes  a  day  or  so  after.  In  some  ea^es  the 
pain  is  acute  and  irregular,  in  others  of  a  dull,  aching  character,  and 
in  a  few  both  varieties  of  pain  coexist.  The  form  of  suffering  may 
be  likened  to  a  very  great  aggravation  of  all  the  disagreeable  feelingi- 
of  an  ordinarj'  menstruation. 

The  clinical  history  (so  far  as  symptoms  are  concerned)  in  the 
inter-menstrual  period  closely  resembles  that  of  corporeal  tndcjme- 
tritis. 

Physical  Signs. — These  are  briefly  as  follows:  Aniemia  of  the 
uterus,  indicated  by  the  pale  appearance  of  the  cervix,  as  seen  through 
the  speculum,  and  suggested  by  amenorrhosa ;  enlargement  and  in- 
duration of  the  uterine  walls,  as  detected  by  touch  and  sound ;  in- 
creased length  of  the  cavity  of  the  utenis  without  increase  of  the 
lateral  and  autero-posterior  diameters ;  slight  retraction  of  the  lips 
of  the  08  externum,  and  the  small  size  of  the  cervical  canal  compai-ed 
with  the  size  of  the  walls  of  the  cervix. 

The  hardness  of  the  uterus  is  a  most  valuable  sign,  but  one  that 
is  not  easily  detected.  To  the  touch,  the  uterus  does  not  in  all  cases 
appear  to  be  more  dense  than  the  virgin  uterus,  but  where  it  is  en- 
larged it  is  softer  in  consistency,  except  in  sclerosis ;  hence,  when 
there  is  an  increase  in  size  and  induration,  not  due  to  fibroma,  the 
evidence  is  in  favor  of  sclerosis. 

In  the  great  majority  of  cases  the  uterus  is  more  tender  than  iu 
any  other  affection,  except  acute  metritis,  and  endometritis  with  flex- 
ion. The  touch  excites  this  sensitiveness,  and  the  passage  of  the 
sound  causes  marked  pain. 

Prognosis. — Sclerosis  being  a  permanent  change  of  structure, 
recovery  with  or  without  treatment  is  the  exception.  By  relieving 
any  comphcation  which  may  be  present,  such  as  displacement,  the 
patient  may  be  made  sufiiciently  comfortable  to  reach  the  menopause, 
and  then  recovery  may  take  place. 

Sclerosis  of  the  cervix  may  be  relieved  to  a  great  extent,  some- 
times completely,  by  trachelorrhaphy,  if  the  cervix  has  been  lacer- 
ated. 

In  case  the  cervix  has  not  been  injured  its  size  can  be  I'educed, 
and  the  tissues  may  become  softened  and  the  nutrition  im]iroved  by 
taking  out  a  V-shaped  piece  on  each  side,  and  bringing  the  parts  to- 
gether, as  in  the  operation  for  laceration. 

Causation . — The  causes  of  this  affection,  given  in  the  Hteyature 
f>f  medicine,  are  che  same  as  those  of  almost  all  other  inflammatory 


SCLEROSIS  OF   THE   UTERUS.  223 

diseases  of  the  uterus.  In  the  cases  wliich  liave  come  under  my  own 
observation,  tliey  were  either  acute  metritis  following;  child-bearing, 
or  miscarriage  or  long-continued  general  endometritis,  and  injuries 
to  the  cervix  during  kbor. 

This  leads  me  to  believe  that  these  are  the  only  causes  of  this 
affection.  In  fact,  as  sclerosis  is  the  result  of  a  deranged  nutrition 
of  an  inflammatory  nature,  it  follows  that  the  cause  must  be  a  pre- 
ceding metritis,  partial  or  general. 

Treaty// enf.— Sclerosis  is,  of  course,  a  preventable  disease  in  the 
majority  of  cases.  If  the  inflammatory  affections  which  lead  to  it 
are  carefully  managed  the  structural  changes  will  be  avoided,  except- 
ing in  severe  puerperal  metritis. 

When  once  the  changes  in  the  tissues  which  constitute  true  scle- 
rosis have  occurred,  it  is  still  a  question  w^hether  any  known  treat- 
ment can  entirely  relieve  it.  As  already  stated  in  the  prognosis, 
benefit  may  be  obtained  by  removing  complications,  such  as  lacera- 
tion of  the  cervix.  In  ihe  hope  of  causing  absorption  of  the  areolar 
tissue,  mercury,  iodine,  copper,  and  belladonna  have  all  been  em- 
ployed ;  and,  it  is  needless  to  say,  that  the  hot- water  douche  has  also 
been  frequently  tried. 

Dr.  Noeggerath,  of  New  York,  recommends  amputation  of  the 
cervix,  permitting  the  stump  to  heal  by  granulation  instead  of  cover- 
ing it  over  with  vao;inal  mucous  membrane.  This  he  deems  advisa- 
ble,  not  only  in  the  hope  of  relieving  the  sclerosis  and  to  counteract 
the  effect  of  the  operation,  but  also  to  prevent  the  development  of 
malignant  disease. 

So  far  as  my  own  personal  observation  goes,  I  am  obliged  to  say 
that  I  have  not  seen  much  benefit  from  any  such  treatment,  and  have 
come  to  look  upon  the  disease  as  an  incurable  one. 

There  is  one  remedy  which  promises  to  be  useful,  and  that  is 
electricity ;  but  I  have  not  had  experience  enough  in  its  use  to  enable 
me  to  speak  definitely  regarding  it.  I  may  say,  however,  that  it 
promises  more  than  anything  else  that  I  am  familiar  with,  but  more 
extensive  observation  is  necessary  to  determine  its  true  value. 

HISTORY    OF    CASES. 

Sclerosis  of  the  Cervix  Uteri. — This  case  is  one  of  the  very  few 
that  I  have  seen  of  sclerosis  of  the  cervix,  not  accompanied  with 
laceration.  It  is  possible  that  the  cervix  had  been  lacerated  during 
one  of  the  patient's  confinements,  and  that  the  wound  had  healed, 
but  I  could  not  find  any  trace  of  such  injury. 

The  patient  was  thirty-one  years  old,  and  had  borne  four  chil- 


224  DISEASES  OF   WOMEN. 


I 


dren  ;  the  last  one  three  yeare  before  the  time  when  this  history  was 
taken.  She  did  not  recover  from  this  continement  as  well  as  she 
had  in  previous  ones,  but  I  could  not  get  any  hist<jry  of  serious 
puei'peral  ditrease  at  that  time. 

After  the  coniinement  her  health  was  poor,  and  she  gave  the 
history  of  some  uterine  disease.  Her  menstruation  was  normal.  l)Ut 
attended  with  more  pelvic  pain  than  formerly.  Slie  had  snlleied 
from  leiicori-hoea,  but  this  had  gradually  diminished.  At  my  first  ex- 
amination I  found  the  body  of  the  uterus  normal,  but  the  cervix  was 
much  enlarged  and  hard  to  the  touch ;  the  os  was  circular  and  small 
in  proportion  to  the  size  of  the  cervix — it  was  an  inch  and  three 
quarters  in  diamotsr.  To  the  toucli  the  cervix  appeared  to  be  as 
large  as  the  body  of  tlie  uterus.  There  was  no  otlier  lesion  found 
except  that  there  was  prolapsus  in  a  sliglit  degree.  She  was  treated 
with  the  hot  douche  and  applications  of  tincture  of  iodine,  but 
without  effect.  I  then  removed,  with  the  hawkbill  scissors,  a  lai'ge 
V-shaped  piece  from  the  lateral  walls  of  the  cervix,  and  closed  the 
wound  with  sutures,  making  an  operation  like  that  for  bilateral  lacer- 
ation. Healing  was  prompt  and  complete,  and  the  size  of  the  cer- 
vix— at  least,  the  vaginal  portion  of  it — was  much  reduced. 

She  was  better  for  tlie  operation,  and  at  the  end  of  one  year  I 
found  that  the  whole  cervix  was  nearly  of  its  normal  size,  and  that 
the  tissues  were  soft  and  more  vascular.  The  operation  liad  the 
effect  of  changing  the  nutrition  of  the  parts,  and  causing  absorption 
of  the  new  tissue. 

In  sclerosed  tissue  due  to  laceration  of  the  cervix,  1  have  fi*e- 
quently  seen  such  favorable  changes  after  operations. 

ILLUSTRATIVE    CASES. 

Sclerosis  Uteri,  following  Puerperal  Metritis. — This  patient  was 
thirty-fiv^e  years  old,  had  been  pregnant  five  time;^,  and  given  birth 
to  four  living  children,  "While  pregnant  at  the  seventh  month  with 
her  fourth  child  she  received  an  injui'v  which  caused  her  to  give 
birth  to  a  dead  f<etus  a  few  days  afterward. 

During  her  fifth  pregnancy  she  received  a  shock  from  seeing  a 
friend  in  a  convulsion  ;  labor  came  on  immediately,  and  she  was  de- 
livered of  a  seven  months'  child.  Soon  after  her  confinement  she 
complained  of  pain  and  tenderness  in  the  region  of  the  uterus,  fol- 
lowed by  fever.  These  synijitoms  extended  over  a  period  of  three 
weeks,  and  there  can  be  little  doubt,  from  the  history  given,  that 
she  had  acute  puerperal  metritis,  which  left  her  health  pennanently 
impaired.     Since  that  time  her  menses  have  been  irregular,  scanty, 


SCLEROSIS   OF  THE   UTERUS.  225 

and  attended  with  paiii.  At  times  she  lias  a  menstrual  molimen,  but 
no  catanienial  flow.  During  the  hist  year  she  has  menstruated  twice, 
the  hist  time  three  months  ago.  This  is  the  previous  history  of  the 
case. 

She  now  suffers  from  extreme  debihty  and  anajmia,  which  is 
shown  by  her  general  appearance ;  she  also  complains  of  ill-defined 
aching  i)ains  tliroughout  the  pelvis,  and  in  the  sacral  region  ;  occa- 
sionally she  has  very  slight  leucorrh(jea.  Her  digestive  organs  are 
also  very  much  deranged,  and  her  nervous  system,  from  the  joint 
action  of  disease  and  drugs,  is  a  miserable  wreck. 

By  physical  exploration  I  find  that  the  uterus  is  enlarged,  being 

■  three  quarters  of  an  inch  longer  than  normal.     The  body  and  cervix 

I  are  tender  to  the  touch,  and  the  sound  carried  into  the  cavity  gives 

extreme  pain.     The  cervix  is  indurated  and  smooth,  and  the  os  is 

;  smaller  and  more  circular  than  is  usually  found  in  those  who  have 

borne  children. 

Exploring  the  cavity  with  the  sound,  I  find  that  wliile  the  longer 
diameter  is  considerably  increased  the  antero-posterior  and  lateral 
diameters  are  shortened.  The  uterine  walls  appear  to  lie  in  close 
contiguity,  so  that  it  is  impossible  to  turn  the  sound  far  in  any  direc- 
tion. These  signs  obtained  by  the  probe  are  of  vast  importance,  for 
they  indicate  clearly  that  the  enlargement  of  the  uterus  is  due  to  an 
actual  increase  in  the  walls  of  the  organ,  and  not  a  mere  expansion 
of  its  cavity.    In  other  words,  the  growth  is  concentric,  not  eccentric. 

The  cervix,  as  seen  through  the  speculum,  is  notably  pale ;  the 
OS  is  small,  with  its  lips  curved  inward.  This  retraction,  or  drawing 
inward  of  the  os,  is  confirmatory  of  the  opinion  that  the  walls  of  the 
cervix  are  enlarged  more  than  the  mucous  membrane  of  the  cavity. 
When  the  mucous  membrane  of  the  cervix  is  swollen,  and  the  walls 
remain  normal,  the  lips  are  enlarged  or  pouting. 

Briefly,  then,  the  physical  signs  indicate  that  there  exists  a  con- 
dition of  unusual  hardness  and  enlargement  of  the  uterine  walls, 
while  the  relative  size  of  the  cavity  is  lessened.  The  uterus  is  also 
aniTeniic,  as  can  be  seen  from  a  glance  at  the  cervix. 

It  should  be  noted  that  this  patient  has  amenorrhcea — a  condition 
that  is  much  more  common  in  the  young  than  in  those  who  have 
borne  children,  and  is  seldom  found  in  connection  with  enlargement 
of  the  uterus. 

This  form  of  sclerosis  presents  many  points  of  resemblance  to 
that  of  general  endometritis,  but  they  are  essentially  different. 

Contrasthig  sclerosis  with  endometritis  gives  results  as  follows : 
The  one  begins  with  acute  inflammation  of  the  uterus,  the  other 
16 


226  DISEASES   OF   WOMEN. 

does  not;  in  tlie  one  there  is  ainenorrlui'a,  in  the  otlier  inen<)rrli:i<;ia; 
in  the  one  the  uterine  walls  are  enlai'ged  and  the  cavity  diiuinishud, 
while  the  reverse  of  this  obtains  in  the  other ;  the  uterus  in  the  one 
is  indurated  and  anjeniic,  in  the  other  it  is  relaxed  and  hij^hly  eon- 
gestetl.  These  are  i»lain  outline  distinctions,  easily  recognized,  and 
characteristic  of  almost  opposite  pathological  conditions. 

Treatment  and  Proijnimn  of  the  Case. — After  each  menstruation 
an  elfort  was  made,  either  with  leeches  or  puncture,  to  siip])lement 
the  How  by  depletion.  This  was  not  successful.  It  was  ditiicnlt  to 
extract  blood  from  the  aniemic  tissues,  and  what  was  accomplished 
did  not  even  relieve  the  patient.  Blistering  the  cervix  was  tried 
with  some  ajjparent  benefit ;  cantharidal  collodion  was  applied,  and 
a  tampon  used  to  protect  the  vagina  until  vesication  should  take 
])lace.  This  was  repeated  several  times  at  intervals  of  two  weeks, 
and  the  patient  had  less  pain  in  the  uterus  and  gained  a  little,  but 
whether  from  the  blistering  or  tonics  and  general  supjioi'ting  treat- 
ment, could  not  be  stated  with  certainty.  Iodine  was  next  tried  ;  it 
was  applied  to  the  canal  and  vaginal  surface  of  the  cervix  thoroughly 
twice  a  week,  but  she  did  not  seem  to  improve  nmch. 

About  this  time  some  one  in  England  reported  good  results  in 
obstinate  uterine  affections  from  vaginal  suppositories  containing 
mercury.  I  tried  these  until  slight  salivation  was  produced.  Some 
harm,  but  no  benelit  was  the  result.  Finally,  1  may  state  that  some 
relief  was  obtained,  but  not  much.  She  profited  from  constitutional 
treatment,  but  not  much  if  any  from  local  medication.  Considera- 
ble relief  was  oljtained  by  wearing  a  Peaslee's  ring-pessary,  which 
gave  a  little  support  to  the  uterus,  but  it  caused  irritation,  and  had 
to  be  removed. 

When  she  was  greatly  fatigued,  and  suffered  more  pain  than 
usual,  a  cotton  tampon  gave  relief  also. 

I  lost  sight  of  the  patient  for  a  number  of  years,  but  recently  she 
returned  to  the  city  and  called  to  see  me  about  some  trouble  of  her 
digestion.  She  told  me  then  that  she  never  fully  recovered  until  the 
menopause,  which  occurred  at  forty-six.  Since  that  time  she  had 
been  faii'ly  well. 

The  uterus,  though  larger  than  it  should  have  been  at  her  age, 
w'as  smaller  than  when  under  ol)servation.  fourteen  years  before. 

Sclerosis  Uteri,  resulting  from  Endometritis  and  General  Congestion. 
— The  patient  was  twenty-four  years  old  when  first  seen.  She  was 
highly  refined,  and  of  a  well-marked  nervous  temjierament.  She 
began  to  menstruate  at  the  age  of  fourteen,  and  had  continued  so  to 
do  regularly,  but  had  always  had  slight  pain  at  the  menstmal  periods, 


SCLEROSIS  OF  TUE  UTERUS.  227 

and  was  unusually  nervous  and  irritable  at  such  times.  She  was 
married  at  twenty-two,  and  soon  after  began  to  have  backache,  leu- 
corrhcea,  and  more  pain  than  formerly  during  menstruation,  and  the 
flow  was  more  free. 

These  symptoms  gradually  increased,  and  her  general  liealth  failed 
considerably.  Pain  in  the  uterus  and  general  pelvic  tenesmus  were 
added  to  her  other  symptoms,  and  after  suffering  for  two  years  in 
this  way  she  came  under  my  care. 

I  then  found  the  uterus  larger  than  it  should  have  been,  and  its 
tissues  softer  than  normal,  especially  those  of  the  cervix.  The  canal 
of  the  cervix  was  larger  than  normal,  and  the  whole  uterus  was 
tender  to  the  touch.  Passing  the  sound  caused  severe  pain.  There 
was  considerable  erosion  of  the  cervix,  the  os  externum  was  di- 
lated, and  the  mucous  membrane  was  highly  congested.  There 
was  a  free  muco-purulent  discharge  which  irritated  the  vagina  and 
vulva. 

The  usual  local  treatment  for  endometritis  was  employed,  and 
the  ordinary  means  were  used  to  improve  her  general  health.  Appli- 
cations of  nitrate  of  silver  (which  I  used  at  that  time,  according  to 
the  advice  of  my  former  teachers)  caused  great  pain,  and  were  given 
up  for  milder  means,  such  as  tincture  of  iodine,  and  tannin  and  glyc- 
erin. She  improved  very  slowly,  and  about  ten  months  after  she 
came  under  my  care  she  went  to  Europe  with  her  husband,  who  was 
called  there  on  business.  She  remained  in  England  for  about  five 
years,  and  occasionally  was  treated  by  a  distinguished  physician 
there. 

Excepting  various  kinds  of  vaginal  injections  she  had  no  local 
treatment  while  in  England.  Her  general  health  improved  very 
much,  and  she  bore  her  local  troubles  without  complaint. 

Upon  her  return  to  this  country,  I  found  that  her  menstrual  flow 
had  diminished  until  she  had  less  than  before  her  man-iage.  There 
was  very  little  leucorrhoea,  and  less  pelvic  tenesmus.  There  was 
quite  as  severe  dysmenorrhoea,  and  she  had  intermittent  pain  in  the 
uterus  of  a  neuralgic  character.  The  uterus,  taken  as  a  whole,  was 
a  little  smaller,  and  indurated  to  the  touch ;  the  canal  of  the  cervix 
and  the  cavity  of  the  body  were  decidedly  diminished  in  caliber,  and 
still  tender  to  the  touch  of  the  uterine  sound.  The  os  externum  was 
contracted,  and  its  lips  in  place  of  being  everted  as  formerly  were 
now  slightly  curved  inward.  In  place  of  the  soft  vascular  condition 
of  the  cervix,  present  when  she  was  first  examined,  it  was  now 
round,  well  defined,  and  rather  angpmic  in  appearance. 

It  was  only  by  referring  to  my  notes  of  the  case,  taken  at  the 


228  DISEASES   UF   WOMEN. 

first  examination,  that  I  cuuld  fully  ivalize  the  change  which  had 
taken  place. 

I  treated  her  for  a  short  tinn.;  in  the  hope  of  relieving  her  dys- 
nienorrhtea  and  uterine  jjains,  but  without  much  hencfit ;  and,  as  she 
was  able  to  get  along  by  resting  at  her  menstrual  ])eriod,  she  was  dis- 
missed with  the  advice  to  await  the  menopause,  when  in  all  })roba- 
bility  she  would  be  relieved. 


CHAPTER   XIII. 

MEMBEANOUS    DYSMENOERHCEA. 

I  SHOULD  prefer  to  call  this  iiffection  membranous  menorrhoea, 
believing  that  the  term  would  be  more  appropriate,  but  as  the  original 
name  has  been  longer  in  use,  and  is  familiar  to  the  profession,  I  shall 
not  attempt  to  change  it. 

This  is  an  affection  which,  although  rather  rare,  commands  very 
urgently  the  attention  of  the  gynecologist,  because  of  the  dreadful 
suffering  which  it  gives  rise  to,  and  the  obstinacy  with  which  it  has 
heretofore  resisted  treatment.  There  is  a  marked  uniformity  about 
this  disease.  In  its  pathology  and  clinical  history  it  varies  but  little 
in  different  cases.  A  number  of  affections  resemble  it  to  a  limited 
extent,  but  it  stands  out  well  defined,  and  is  easily  detected  by  the 
experienced  diagnostician. 

Pathology. — ^An  exfoliation  in  mass  of  the  mucous  membrane  of 
the  cavity  of  the  body  of  the  uterus  at  the  menstrual  period  is  the 
chief  lesion  in  this  affection.  Microscopically,  the  mass  presents  all 
the  histological  elements  of  the  tnie  mucous  membrane  of  the  uterus, 
including  the  utricular  glands,  unchanged  l)y  any  new  or  abnormal 
elements.  When  it  is  expelled  entire,  it  represents  a  complete  cast 
of  the  cavity  of  the  uterus,  and  is  triangular,  with  an  irregular  open- 
ing at  each  of  the  angles,  the  one  representing  the  internal  os  uteri, 
and  the  others  corresponding  to  the  ostia  of  the  Fallopian  tubes. 
This  membrane  is  rather  ragged  on  the  outer  surface,  but  smooth  on 
the  inner,  and  looks  exactly  as  the  lining  membrane  of  the  uterus 
does  when  in  position.  The  size  is  usually  about  an  inch  long  and 
less  than  that  in  width,  and  is  generally  somewhat  larger  than  the 
normal  proportions  of  the  cavity  of  the  uterus  ;  but  this  is  not  always 
the  case.  In  this  respect  it  is  like  the  decidua  of  pregnancy ;  in 
fact,  in  general  appearance  it  closely  resembles  the  decidua  vera,  but 
there  is  a  decided  difference  in  its  microscopic  elements,  sufficient  at 
least  to  distinguish.     This  similarity  of  the  two  membranes  has  led 


230  DISEASES   OF   WOMEN. 

to  their  being  called  the  decidua  gravida  and  the  deeidiia  menstrn- 
alis,  the  foi'iiier  being  the  mucous  membrane  as  seen  in  abortion  at  a 
very  early  stage  of  gestation,  the  other  the  membrane  as  thrown  off 
at  menstruation  in  this  morbid  form. 

Comparing  the  changes  which  the  raucous  membrane  undergoes 
in  membranous  dysmenorrini'a  with  its  changes  in  normal  menstru- 
ation, the  difference  is  as  follows :  In  normal  menstruation,  if  we 
accept  the  views  of  Dr.  Williams,  of  London,  the  whole  mucous 
membrane  undergoes  fatty  degeneration,  disintegration,  and  elimina- 
tion ;  whereas  in  membranous  dysmenorrhcea  the  mucous  membrane 
becomes  separated  from  the  walls  of  the  uterus  without  being 
changed  or  disintegrated ;  exfoliation  and  expulsion  sim])ly  occur. 
The  way  in  which  the  separation  of  the  mucous  membrane  takes 
place  is  not  positively  known.  It  is  presumed,  however,  that  fatty 
degeneration  in  the  deeper  structures  of  the  membrane  takes  place, 
and  thereby  it  l)ecomes  detached  from  the  uterus.  It  is  possible, 
also,  that  the  capillary  hoemorrhage,  instead  of  occurring  on  the  free 
surface  of  the  membrane,  takes  place  in  the  deeper  structures,  and 
in  that  way  dissects  off  the  membrane.  This,  however,  is  hypo- 
thetical, and  needs  confirmation.  Sometimes  the  membrane  is  ex- 
pelled in  shreds,  which  suggests  that  the  exfoliation  either  occurs 
in  spots  or  sections,  or  else  that  the  membrane  is  completely  6e|> 
arated  from  the  uterus,  but  becomes  broken  up  either  during  ex- 
pulsion or  in  handling  it  afterward.  It  is  iimch  more  probable  that 
it  is  completely  exfoliated  and  broken  up  subsequently  than  that  it 
is  separated  in  circumscribed  patches.  All  these  facts  lead  to  the 
conclusion  that  the  affection  is  a  perversion  of  nutrition  and  func- 
tion rather  than  an  organic  disease,  inflammatory  or  otherwise,  which 
gives  rise  to  this  peculiar  condition  of  the  mucous  membrane  at 
menstruation.  It  is  clearly  evident  that  there  is  nothing  pathoh»gi- 
cal  in  the  condition  of  the  mucous  membrane  itself,  but  that  the 
whole  morbid  process  consists  in  the  separation  of  the  membrane  in 
mass,  in  place  of  disintegration,  which  is  the  normal  character  of 
the  mucous  membrane  in  menstiniation.  There  are  other  views 
regarding  the  pathology  of  this  affection :  one,  that  it  is  the  result 
of  gestation,  which  is  arrested  at  a  very  early  stage,  and  that  the 
membrane  thrown  off  is  really  a  decidua  vera.  That  this  theory  is 
fallacious  will  be  seen  when  the  physical  signs  of  this  affection  are 
discussed. 

The  idea  that  it  is  an  inflammatory  affection  is  not  well  sustained. 
No  such  product  or  result  of  inflammation  is  found  elsewhere  in  the 
mucous  membranes  of  the  body,  nor  is  it  necessary  that  inflammation 


MEMBRANOUS  DYSMENORRIICEA.  231 

of  any  part  of  the  uteiTis  should  be  present  in  order  to  produce 
membranous  dysmenorrlicea. 

Associated  with  this  membranous  dysmenorrhcea  we  occasionally 
find  iniiammatory  conditions,  but  not  of  the  mucous  membrane  of 
the  cavity  of  the  body.  There  may  be,  and  often  is,  a  general  hy- 
perajmia  of  the  uteras  and  vagina,  but  usually  it  is  not  greater  than 
that  which  is  seen  in  normal  menstruation. 

There  is  occasionally,  in  cases  of  long  standing,  cervical  endome- 
tritis, but  this  does  not  extend  to  the  body  of  the  uterus.  In  fact,  I 
believe  that  a  well  defined  endometritis  can  not  occur  at  the  same 
time  as  membranous  dysmenorrhcea.  This  affection,  then,  is  cer- 
tainly siii  yeneris,  and  is  not  the  result  of  inflammation  in  any  form 
or  in  any  stage  of  the  inflammatory  process  ;  neither  is  it  a  utero-ges- 
tation  ending  in  abortion  at  a  very  early  stage  of  pregnancy,  as  some 
have  maintained ;  neither  does  the  membrane  partake  of  the  nature 
of  any  of  the  morbid  neoplasms  which  occur  in  mucous  membranes 
elsewhere  in  the  body. 

The  mucous  membrane  in  this  affection  is  developed  in  the  nat- 
ural manner  after  each  menstmation,  and  the  gross  appearances  and 
histological  composition  of  this  structure  show  that  it  is  normal,  and 
differs  in  no  way  from  the  mucous  membrane  of  the  uterus  up  to 
the  time  when  the  menstrual  flow  is  about  to  begin.  Perhaps  there, 
is,  in  some  cases,  an  increase  in  the  quantity  of  the  membrane,  but 
only  to  a  very  limited  extent,  if  at  all.  In  short,  the  only  pathol- 
ogy connected  with  this  affection  is  in  the  manner  in  which  the 
membrane  is  thrown  off. 

Symptomatology. — This  affection  occurs  in  single  and  married 
women — about  as  often  in  one  class  as  the  other,  perhaps.  It  also 
occurs  in  those  who  have  bome  children,  but  in  most  of  the  cases 
that  I  have  seen  in  married  women  the  patients  have  been  sterile. 
The  recurrence  of  the  menstruation  is  generally  regular ;  sometimes 
it  is  delayed,  and  sometimes  there  is  a  sense  of  pelvic  discomfort 
before  the  menstrual  flow,  but  not  always.  The  chief  symptom  is 
the  pain  which  comes  on  usually  during  the  first  day,  sometimes 
later,  and  increases  in  severity,  and  is  somewhat  intermittent  in 
character  until  the  membrane  is  expelled,  when  it  rather  abruptly 
subsides. 

The  flow  sometimes  is  scanty  previous  to  the  expulsion  of  the 
membrane,  and  after  that  it  is  generally  quite  free ;  at  times  abnor- 
mally so,  and  occasionally  small  clots  are  passed. 

Sometimes  there  is  a  leucorrhceal  discharge  succeeding  the  men- 
strual flow,  the  discharge  being  occasionally  tinged  with  blood.     In 


232 


DISEASES   OF   AVOMEX. 


other  cases  the  meiistnial  flow  subsides  after  the  expulsion  of  the 
memljrane,  and  no  leueorrli(ea  of  any  account  occurs  afterward. 

There  is  really  nothiufj;  in  the  clinical  history  of  this  affection  by 

which  it  can  be  positively  distinguished  from  dysnienorrhcea  due  to 

„^^^,  other  causes.  Hence 


5S«i& 


Fig 


102. — Sketch  of  a  dysmenorrhceal  membrane,  as   seen 
under  water  (Simpson). 


the  diagnosis  nuist 
always  depend  upon 
the  j)hysical  signs. ' 

— In  order  to  make 
a  diagnosis,  it  is  ab- 
solutely necessary 
that  the  men»brane 
expelled  should  be 
preserved  and  ex- 
amined. The  gross 
ajipearances  of  the 
specimen  are  usual- 
ly all  that  is  neces- 
sary to  satisfy  the 
diagnostician  re- 
garding the  nature 


of  the  affection,  but 
in  cases  where  there 
is  a  doubt  the  microscope  must  be  called  in  to  aid  in  the  diagnosis. 

The  morbid  materials  expelled  from  the  uteriLs  whicli  simulate 
the   membrane    produced    in    this 
affection  are  the.decidua  expelled 
in  abortion  in  the  earliest  stages  of 


pregnancy  ;  the  masses  of  filjrin 
which  have  formed  in  the  uterus 
in  menorrhagia  ;  very  dense  masses 
of  secretion  from  the  cervix ;  and 
the  membranous-looking  shreds  ex- 
pelled from  the  cervix  and  vagina 
after  astringent  or  caustic  applica- 
tions. 

The  decidiia  in  early  abortion 
is  most  difficult  to  distinguish  from 
the  menstrual  membrane.  In  the 
early  abortion  the  membrane  ex- 
pelled is   usually  larger  and  more 


103. — Membrane   of   membranous 
dvsmenorrhoea  (Barnes). 


MEMBRANOUS  DYSMENORRIICEA. 


233 


,trl  >''i,<A>?»Vv, 


ovoid  or  round,  and  not  so  markedly  triangular  as  the  decidua  of 
menstruation,  and  is  also  thicker,  and  usually  is  accompanied  with 
villi  of  the  chorion.  If  there  is  still  a  doubt,  the  microscope  re- 
veals the  fact  that  the  menstrual  membrane  possesses  only  small 
cells,  while  those  of  the  decidua- vera  menibrane  are  so  great  as  to 
be  easily  distinguislied.  There  is  a  decided  microscopic  difference 
in  the  epithelium,  the  tubes,  and  the  inter-glandular  tissue.  This 
difference  between  the  two  membranes  is  not  only  in  the  decidua 
of  early  abortion,  but  also 
in  the  decidua  of  extra-uter- 
ine pregnancy.  In  being 
tlnis  able  to  distinguish  be- 
tween the  decidua  of  preg- 
nancy and  the  membrane  of 
menstruation,  the  only  great 
difficulty  in  the  diagnosis  is 
overcome. 

The  shreds  of  fibrin  ex- 
pelled from  the  uterus  some- 
times look  membranous  in 
form,  but  have  none  of  the 
structure  ol  the  mucous 
membrane,  and  hence  can 
be  detected  on  cursory  ex- 
amination. The  same  may 
be  said  of  the  masses  of 
unusually  dense  secretion  of 
the  cervix.  The  membra- 
nous shreds  that  come  from 
tbe  cervix  and  the  vagina 
as  the  result  of  astringent 
and  caustic  applications  resemble  at  first  sight  the  menstrual  mem- 
brane. The  most  perfect  of  these  exfoliations  from  the  vagina  I 
have  seen  after  the  use  of  the  persulphate  of  iron  ;  these  speci- 
mens, however,  are  much  thinner  and  differ  entirely  in  structure, 
being  made  up  mostly  of  epithelium,  and  therefore  need  not  be  mis- 
taken for  the  menstrual  membrane. 

With  due  attention  to  the  membrane  expelled,  the  diagnosis  can 
be  made  with  great  certainty. 

Causation. — Discarding  the  current  views  regarding  membranous 
dysmenorrhoea — that  is,  that  it  is  due  to  infiammation,  or  else  the  re- 
sult of  gestation — one  is  left  without  any  very  rational  view  to  offer 


Fig.  104. — The  decidual  membrane  expelled  in 
abortion.  The  serotinal  attachment  is  drawn 
out  to  a  pedicle. 


23-1  DISEASES  OF   WOMEN. 

regarding  its  causation.  While  it  is  not,  perhaps,  the  part  of  wisdom 
to  discredit  the  accepted  views  on  any  question  in  medicine  until  one 
has  something  more  reliable  to  otTer,  still,  if  the  causes  assigned  can 
be  readily  shown  to  be  incorrect,  it  is  intinitely  better  and  safer  to 
be  entirely  in  ignorance  of  the  causes  of  things  than  to  attribute 
them  to  the  wrong  causes.  Fortunately,  however,  while  I  find  my- 
self at  variance  with  most  of  the  recent  authorities  regarding  the 
cause  of  this  affection,  I  am  in  perfect  harmony  with  the  views  of 
Dr.  Oldham,  who  was  the  first  to  discover  "  dysmenorrhtjea  mem- 
branacea.'' 

Dr.  Oldham  distinctly  pointed  out  the  characteristics  of  this  affec- 
tion, and  stated  that  the  membrane  is  formed  under  abnormal  ovarian 
stimulus  ;  and  I  am  fully  satisfied  that  he  was  not  only  the  discoverer 
of  the  disease,  but  also  conceived  the  true  idea  regarding  the  cause  of 
it — viz.,  some  undue  ovarian  intiuence  or  sexual  excitation.  In  other 
words,  it  would  appear  to  be  some  derangement  of  innervation  and 
nutrition. 

Taking  this  view  of  the  causation,  I  expect  to  find  myself  in  har- 
mony with  the  neurologists  at  least.  This  class  of  specialists  mani- 
fests a  willingness  to  trace  many  diseases  originally  to  some  derange- 
ment of  the  nervous  system,  when  they  find  anything  like  good 
reasons  for  so  doing.  Hence.  I  expect  their  support  in  choosing,  as 
1  do,  to  believe  that  the  starting-point  in  the  pathology  of  this  affec- 
tion must  be  some  derangement  of  innervation  produced  by  disease 
or  functional  derangement  of  the  ov^aries.  Confirmation  of  this  view 
regarding  the  cause  of  membranous  dysmenorrhnea  may  be  found  in 
studving  the  agencies  which  give  rise  to  other  morbid  states  of  the 
uterus,  like  the  fibroid  growth,  for  example,  which  in  its  anatomical 
elements  does  not  differ  especially  from  the  tissues  of  the  uterus 
from  which  it  springs;  and,  if  we  could  find  the  cause  of  this  devi- 
ation from  healthy  nutrition,  it  might  be  applicable  to  the  disease 
under  discussion.  But,  unfortunately,  the  causes  of  fibroid  tumors 
given  in  our  literature  are  unsatisfactory,  and  by  no  means  well  sus- 
tained. 

From  the  fact  that  uterine  fibroids  are  more  common  in  sterile 
women  than  in  others,  it  would  appear  that  sterility  predisposes  to 
their  development,  and  perhaps  no  better  explanation  of  the  cause  of 
these  growths  has  ever  been  given  than  that  of  my  somewhat  hu- 
morous friend,  who  said  that  "the  uterus,  being  prepared  for  normal 
work  and  not  finding  it  to  do,  took  up  the  development  of  fibroids 
as  a  sort  of  occupation  for  its  formative  powers.""  May  it  not,  then, 
l)e  that  a  well-defined  predisposition  to  reproduction,  uncalled  for  by 


MEMBRANOUS  DYSMENORRHOEA.  235 

gestation,  excites  this  morbid  action  on  the  part  of  the  uterus  which 
leads  to  this  abnormal  exfoliation  of  its  mucous  membrane  ?  This 
view  might  at  least  be  entertained,  because  in  other  cases,  when  we 
are  unable  to  detect  the  cause  of  a  disease  in  something  that  is  tan- 
gible, we  usually  attril)uto  it  to  deranged  innervation  and  conse- 
quent malnutrition.  This  view  of  the  causation  is,  to  some  extent, 
sustained  by  the  etfect  of  medicines  upon  the  lesions.  This  aifec- 
tio!i  has  always  been  recognized  as  one  that  is  often  difficult  to  cure, 
many  times  incurable,  in  the  hands  of  the  most  competent  phy- 
sicians and  surgeons.  This  possibly  may  have  been  due  to  misap- 
prehension of  the  nature  and  cause  of  the  disease,  and  hence  falla- 
cious therapeutics,  rather  than  to  the  incurable  character  of  the 
disease. 

In  favor  of  this  line  of  thought  I  may  state  that  the  patients 
whom  I  have  treated  in  years  past,  on  the  theory  that  the  cause 
was  indammatory,  have  derived  little  benefit,  while  those  who  were 
treated  foi*  deranged  innervation,  malnutrition,  and  undue  ovarian 
excitation,  have  made  very  much  better  progress.  I  am  inclined  to 
attribute  most  of  the  trouble  to  ovarian  influence,  the  condition  of 
the  ovaries  being  that  of  an  undue  nerve  excitation  and  possible 
congestion.  I  have  been  led  to  this  belief  by  two  facts :  that  the 
majority  of  the  patients  that  I  have  seen  have  been  subjects  of  a 
highly  nervous  organization,  and  in  most  of  them  there  has  been 
tenderness  of  the  ovaries,  and  pain  at  times,  without  there  being  any 
evidence  of  ovaritis. 

The  rheumatic  diathesis  is  said  to  favor  this  affection,  and  it  is 
possible  that  this  may  be  so,  although  I  am  unable  to  recall  any  of 
my  patients  as  being  rheumatic ;  neither  have  I  been  able  to  trace 
it  to  the  tubercular  or  strumous  diathesis,  nor  to  syphilis.  It  is 
certain,  however,  that,  if  either  of  these  conditions  existed,  it  would 
have  its  influence  in  helping  to  keep  up  the  uterine  trouble,  and 
every  effort  should  therefore  be  made  to  relieve  it  by  treatment. 

Treatment. — The  treatment  of  this  affection  is  necessarily  both 
palliative  and  curative.  While  the  patient  is  suffering  during  the 
expulsion  of  the  membrane,  it  is  very  necessary  to  relieve  the  j)ain 
as  far  as  possible.  This,  of  course,  can  be  most  promptly  done  by 
the  use  of  opium,  which  should  be  avoided  if  possible,  however,  be- 
cause of  its  after-effects. 

Chloral  hydrate  answers  fairly  well  in  some  cases.  I  was  induced 
to  try  this  agent  by  the  accounts  given  of  its  effects  in  reheving  the 
pains  of  the  first  stage  of  labor.  I  am  not  sure  that  it  has  any  ad- 
vantages over  chloroform,  camphor,  and  belladonna,  or  conium  and 


236  DISEASES   OF  WOMEN. 

cannabis  Indica ;  in  fact,  in  the  majority  of  cases,  one  has  an  oi> 
portunity  to  try  several  agents,  and,  of  course,  tlie  patient  will  decide 
which  gives  most  relief.  Indications  for  general  treatment  are  to 
quiet  all  nervous  disturbance  and  to  improve  the  general  nutrition 
of  the  mucous  membrane.  It  so  happens  that  when  the  first  part  is 
attended  to  the  latter  will  follow  in  due  order. 

To  quiet  the  nervous  irritation  and  disturbance  there  is  nothing 
that  equals  the  bromide  of  sodium.  This  should  be  given  in  twenty- 
or  thirty-grain  doses  three  times  a  day  for  ten  days  or  two  weeks 
before  the  menstrual  period.  And,  if  the  pain  is  not  severe  enough 
to  require  the  addition  of  some  of  the  remedies  already  named  to  re- 
lieve it,  the  bromide  may  be  continued  throughout  the  menstrual 
period  and  several  days  after.  From  this  it  would  appear  that  the 
bromide  is  to  be  used  continuously ;  but  one  or  two  weeks  in  each 
month  it  can  be  omitted.  When  the  l)romide  has  been  employed 
for  some  time,  and  it  seems  desirable  to  give  it  up,  conium  may  be 
administered  in  moderate  doses  combined  with  camphor,  if  the  pa- 
tient is  weak.  If  there  is  any  evidence  of  the  rheumatic  diathesis, 
the  bromide  of  lithium  should  be  given.  Next  to  quieting  the  nerv- 
ous system,  any  debility  that  may  exist  should  be  overcome  by  nerve 
tonics.  Undue  nervous  excitation  so  often  goes  liand  in  hand  with 
nervous  depression  that  in  many  cases  it  is  necessary  to  combine  the 
tonic  and  sedative  treatment.  All  the  remedies  which  may  be  used 
need  not  be  here  mentioned.  In  regard  to  the  modification  of  nu- 
trition, it  need  only  be  said  that  any  accompanying  derangements  of 
the  digestive  organs  that  may  be  found  should  receive  careful  atten- 
tion ;  but  this  hardly  need  be  mentioned  in  this  connection. 

My  rule  of  treatment  has  been,  after  subduing  all  nervous  dis- 
turbances, to  put  the  patient  upon  the  iodide  of  sodium  in  case  she 
is  in  fair  strength  and  inclined  to  flesh.  If  there  is  amemia,  I  prefer 
the  iodide  of  iron.  If  these  do  not  aecomplLsh  the  object,  I  employ 
mercury,  giving  it  in  small  doses,  never  continuing  it  long  enough 
to  produce  sahvation,  carefully  watching  to  avoid  this.  In  cases  of 
anaemia,  where  I  have  feared  the  debilitating  effect  of  this  alterative, 
I  have  given  the  bichloride  of  mercury  with  iron.  After  keeping 
them  upon  this  treatment  until  I  could  see  some  evidence  of  its 
effects,  I  have  then  put  them  upon  iodine  and  arsenic. 

In  regard  to  local  treatment,  I  have  been  entirely  guided  by  the 
views  of  the  pathology  as  expressed  above,  and  have  therefore  em- 
ployed alteratives  and  sedatives  almost  exclusively.  Of  these  I  have 
found  iodoform  most  effectual.  I  have  also  used  iodine  and  mer- 
cury with  advantage.     In  cases  where  I  have  found  any  complications 


MEMBRANOUS  DYSMENORRHGEA.  237 

I  have  carefully  attended  to  them,  restoring  displacements  and  cor- 
recting flexions,  and  so  on.  Wlien  the  canal  of  the  cervix  lias  been 
at  all  constricted  1  have  enlarged  it  by  incision  and  dilatation. 

When  the  congestion  which  occurs  at  the  menstrual  period  has 
not  subsided  in  a  few  days,  I  have  eini)loyed  the  warm-water  douche. 
After  this,  I  have  applied  to  the  cavity  of  the  uterus  small  bougies 
of  cocoa-butter  with  as  much  iodoform  as  they  would  take  up.  Three 
or  four  grains  of  iodoform  mixed  with  vaseline  that  has  l>een  lique- 
fied by  heat,  and  introduced  through  the  pipette,  is  j^erhaps  the  Ijest 
method  of  applying  it.  This  has  been  introduced  once  a  week  or 
once  every  five  days.  When  there  has  been  much  tenderness,  and 
the  use  of  the  pencils  has  caused  pain,  I  formerly  used  aconite  and 
opium  and  iodine ;  this  I  have  introduced  into  the  cavity  of  the 
uterus.  I  am  now  trjdng  cocaine  to  subdue  the  tenderness  as  a  pre- 
paratory means  to  the  use  of  the  iodoform.  But  so  far  this  new 
remedy  has  not  been  a  perfect  success. 

In  cases  where  this  has  failed  and  the  uterus  was  not  especially 
sensitive  to  intra-uterine  medication,  I  have  instilled  mto  the  uterine 
cavity  a  few  drops  of  a  5-per-cent  solution  of  carbolic  acid,  making 
one  application  a  few  days  after  the  menstrual  flow  and  not  repeat- 
ing it  until  the  next  period.  In  the  interval  I  have  used  the  iodo- 
form. I  have  also. used  the  fluid  extract  of  conium  and  hydrastis 
Canadensis  ;  but  this  I  have  found  gives  more  pain  than  any  of  the 
other  applications  that  I  have  used;  and  so  of  late  I  have  used  an 
infusion  of  the  hydrastis  alone,  which  ajjpears  to  answer  as  well  and 
gives  less  pain. 

HISTORY    OF    CASES. 

Case  I.  Membranous  Dysmenorrhcea  in  a  Married  Lady  who  was 
never  Pregnant. — This  patient  was  forty-one  years  of  age,  of  good 
constitution,  and  had  been  married  eight  years.  She  began  to  men- 
struate at  thirteen,  and  continued  to  do  so  regularly  and  normally 
until  she  was  twenty-one ;  then  she  began  to  have  occasional  pain, 
about  the  menstrual  period,  in  the  region  of  the  ovaries.  About  a 
year  after  this  she  began  to  have  severe  uterine  pains  during  the 
menses,  and  states  that  she  occasionally  passed  masses  that  looked 
like  membrane  from  the  uterus ;  they  were  small,  however,  and  did 
not  appear  at  each  period. 

After  her  marriage  the  pain  at  the  menstrual  periods  became 
worse,  and  almost  every  month  she  passed  a  membranous  cast  of  the 
uterus.  The  usual  history  of  each  menstruation  is  that  the  flow  be- 
gins not  very  free,  and,  after  continuing  for  about  five  hours,  the 
pain  becomes  very  intense  and  lasts  from  three  to  eight  hours,  when 


238  DISEASES   OF   WOMEN. 

she  expels  tlio  membrane  :in<l  the  pain  su])si(les,  tlie  flow  eontimiinf; 
for  a  day  or  a  (hiy  and  a  lialf  after  the  memhrane  has  l^eeii  e\j)elled. 

The  flow,  taken  altogether,  is  not  profuse,  and  only  hists  from 
two  to  two  and  a  half  days,  while  formerly — ^that  is,  before  her  dys- 
menorrha'a  began — it  used  to  continue  from  four  to  Ave  days.  When 
first  seen,  her  general  health  was  good,  but  she  was  rather  liysterical 
and  nervous,  and  was  somewhat  depressed  and  disappointed  because 
she  had  not  had  children. 

She  described  the  suffering  at  lier  menstrual  periods  as  some- 
thinjr  unbearable,  althouiih  it  did  not  last  more  than  a  few  houi-s  at 
a  time.  She  was  flrst  examined  midway  between  the  menstrual 
periods.  The  uterus  was  then  found  to  be  normal  in  size  and  in 
good  position.  The  internal  os  was  rather  sensitive  and  aj)peared 
to  be  slightly  contracted  ;  there  was  also  a  distended  Nabothian 
gland  in  the  middle  third  of  the  cervical  canal,  but  the  uterus  pre- 
sented a  normal  appeai-auce  in  every  other  respect.  There  was  no 
congestion  ;  in  fact,  at  this  time  the  mucous  membi'ane  ap[)eared 
rather  anaemic. 

The  diagnosis  was  left  an  open  question  until  the  next  menstrual 
period,  when  I  obtained  the  membrane  expelled  and  had  it  examined 
by  my  friend  Professor  Frank  Ferguson.  His  report  stated  that  the 
specimen  was  uterine  mucous  membrane  unchanged  in  its  histological 
composition.     This  settled  the  question  of  diagnosis. 

Careful  inquiry  elicited  the  fact  that  she  had  never  been  preg- 
nant, so  far  as  I  could  rely  upon  her  testimony,  which  I  believe  to 
be  accurate  because  of  her  great  desire  to  have  children.  I  also 
learned  that  on  several  occasions  she  had  lived  apart  from  her  hus- 
band, who  was  of  necessity  absent  on  business  for  several  months  at 
a  time,  and  that  she  suffered  just  the  same,  and  at  each  month  there 
was  an  expulsion  of  membrane,  showing  conclusively  that  there  was 
no  possibility  of  mistaking  this  affection  for  pregnancy  and  alx^rtion. 

The  treatment  consisted,  iirst,  in  placing  her  upon  the  following 
mixture :  Half  a  grain  of  the  bichloride  of  mercury,  one  drachm  of 
the  solution  of  the  chloride  of  arsenic,  three  drachms  of  the  tincture 
of  iron  in  a  three-ounce  mixture  of  sirup  and  water.  •  A  teaspoouful 
of  this  was  given,  well  diluted,  after  each  meal.  At  the  same  time 
the  internal  os  was  incised  superticiafly  in  three  places,  dividing 
equally  the  circumference  of  the  canal,  and  the  distended  Kabothian 
follicle  was  punctured  and  evacuated.  • 

A  week  after  this  a  sound  was  introduced  of  full  size,  and  there 
was  less  tenderness;  the  tincture  of  iodine  was  then  applied  from 
just  within  the  internal  os  outwai'd.     At  the  next  menstrual  period 


MEMBRANOUS   DYSMENORRHCEA.  239 

she  had  less  pain,  hut  it  lasted  just  as  long,  and  she  passed  a  mem- 
brane nnchanged,  except  that  it  did  not  appear  so  thick  as  formerly. 

From  this  onward  the  local  treatment  consisted  in  passing  a  full- 
sized  sound  just  beyond  the  internal  os  directly  after  the  menstrual 
period,  and  again  in  two  weeks,  and  in  nearly  every  six  days  about 
two  grains  of  iodoform  mixed  with  vaseline  were  jjassed  into  the  cav- 
ity of  the  uterus,  well  up  toward  the  fundus.  This  local  treatment 
was  continued  without  interruption  for  three  months,  and  the  first 
prescription,  after  it  had  been  taken  for  two  weeks,  was  followed  by 
the  iodide  of  iron,  a  grain  and  a  half  three  times  a  day. 

After  the  second  month,  and  at  the  third  menstrual  period  from 
the  time  that  treatment  began,  she  had  no  pain  and  passed  no  mem- 
brane. At  the  next  period  she  passed  several  shreds,  but  nothing 
like  a  complete  cast  of  the  uterus. 

The  constitutional  treatment,  that  is,  alternating  between  the  first 
prescription  of  mercury  and  arsenic  and  the  iodide  of  iron,  giving 
first  one  for  two  weeks,  and  then  the  other,  was  continued  for  two 
months  longer.  The  application  of  the  iodoform  was  continued 
for  one  month  longer,  once  every  week,  and  once  after  her  menstru- 
ation, at  the  end  of  the  fourth  month  of  the  treatment.  Since  that 
time  she  has  had  no  further  trouble ;  her  menses  are  regular,  lasting 
about  three  days,  and  entirely  without  pain  or  any  discharge  of 
membrane. 

That  was  her  record  at  least  one  year  after  she  gave  up  treatment, 
since  which  time  I  have  not  heard  from  her. 

Case  IT.  Membranous  Dysmenorrhoea  occurring  after  Treatment 
for  Anteflexion  and  One  Miscarriage. — A  lady  of  very  high  culture 
and  over-refinement,  of  a  well-marked  nervous  temperament,  but 
otherwise  of  good  constitution,  came  under  my  observation  when 
twenty-eight  years  of  age ;  she  had  then  been  married  a  year  and  a 
half.  She  menstruated  first  at  fourteen  years,  and  continued  to  do 
so  regularly,  but  with  pain  from  the  very  beginning.  The  pain 
usually  began  a  day  or  so  before  the  flow  and  gradually  diminished 
after.  Her  suffering  at  each  period  gradually  increased  until  her 
marriage,  when  it  became  more  severe.  This,  and  the  fact  that  she 
remained  sterile,  induced  her  to  seek  advice.  I  found  her  suffering 
from  anteflexion  of  the  body  of  the  uterus  and  cervical  endometritis ; 
there  was  also  tenderness  of  the  left  ovary  on  pressure.  She  was 
treated  for  the  flexion,  and  completely  recovered.  The  dysmeuor- 
rhosa  was  entirely  relieved,  and  she  became  pregnant.  During  her 
pregnancy  she  suffered  very  much  from  morning  sickness,  and  at 
the  end  of  the  third  month  began  to  show  some  signs  of  septi- 


240  DISEASES   OF    WuMEN. 

capmia;  slie  then  miscarried,  and  the  ovum  ^va.s  found  to  be  macer- 
ated, and  probably  luid  been  dead  ///  nU  ro  for  two  weeks.  Slie 
recovered  from  this  and  was  quite  well  for  about  a  year,  when  her 
dysmenorrluea  returned ;  she  then  returned  to  be  treated  for  what 
she  supposed  to  be  a  recurrence  of  lier  foi'mer  trouble,  but  1  found 
no  evidence  of  the  former  flexion.  But,  on  inquiry,  I  found  that 
she  [)assed  at  eacli  period  a  membranous  cast  of  the  uterus.  The 
patient  thought  little  of  this,  because  in  former  years,  while  suffering 
from  the  dysmenorrhcea  caused  by  flexion,  she  occasionally  passed 
small  clots  which  looked  somewhat  membranous  in  character,  but  no 
doubt  were  simply  blood-clots. 

She  was  placed  upon  treatment  similar  to  that  employed  in  the 
flrst  case  reported,  except  that  there  was  no  necessity  for  enlai'ging 
the  internal  os  as  in  the  former  case,  the  only  difference  in  the  local 
treatment  being  that  I  used  iodine  in  place  of  iodoform  during  the 
last  two  months  of  the  treatment ;  and  once,  immediately  after  the 
menstrual  period,  I  applied  a  mild  solution  of  carbolic  acid  to  the 
uterine  cavity. 

She  did  not  again  pass  any  membrane  after  the  third  month  of 
treatment,  and  her  pain  from  menstruation  entirely  disappeared. 

Slie  was  dismissed  at  the  end  of  four  months,  and  two  months 
afterward  reported  that  she  was  pregnant.  Three  months  after  that 
time  she  was  examined  and  found  to  be  so,  and  was  progressing  well. 
Since  that  time  I  have  not  seen  liei",  but  have  heard  that  she  gave 
birth  to  a  healthy  child. 

Case  III.  Membranous  Dysmenorrhcea  treated  by  Dr.  Fordyce 
Barker,  of  New  York;  Complete  Recovery. — I  give  the  history  of  the 
following  case  for  two  reasons :  First,  to  show  that  iodofoi'm  was 
employed  in  the  local  treatment,  and  that  the  patient's  recovery  was 
complete ;  and  also  to  take  the  opportunity  of  stating  that  I  believe 
that  Dr.  Barker  was  the  iirst  to  employ  this  agent. 

The  histoiy  is  not  altogether  complete,  because  I  obtained  it  from 
the  patient  herself,  who  was  unable  to  tell  all  that  was  done  for  her ; 
but  I  know  positively  that  she  suffered  from  dysmenorrlKva,  and  that 
she  entirely  recovered  under  the  care  of  Dr.  Barker,  and  has  remained 
well  for  a  number  of  years. 

This  was  an  educated  lady  of  a  well-marked  nervous  temperament ; 
she  began  to  menstruate  at  thirteen,  and  continued  to  do  so  normally 
until  she  was  twenty-six  years  of  age.  At  that  time  she  was  said  to 
have  had  an  acute  attack  of  ovaritis,  and  after  i-ecovering  from  that 
she  had  dysmenorrhcea. 

The  character  of  the  pain  at  her  menstrual  periods  then  appeared 


MEMBRANOUS   DYSMENORRHCEA.  241 

to  ])e  ovarian.  After  suffering  in  this  mauner  for  about  four  or  live 
years  slie  noticed  the  expulsion  of  membranous  casts  of  the  uteras 
at  tlie  menstrual  periods.  JJuring  this  time  and  for  a  year  afterward 
slie  was  regularly  treated  by  her  family  physician,  but  without  relief. 
She  then  consulted  Dr.  Barker  for  her  general  ill-health,  but  did  not 
call  his  attention  to  her  derangement  of  the  menstrual  function. 
She  improved  in  her  general  condition  under  his  care,  but  found  no 
relief  from  the  membranous  menstruation.  She  consulted  him  again 
and  called  his  attention  to  the  uterine  trouble,  and  he  immediately 
))laced  her  under  treatment. 

The  constitutional  remedies  employed  I  do  not  know,  but  the 
local  treatment  consisted  in  dilatation  of  the  cervical  canal  and  the 
application  of  iodoform  to  the  uterine  cavity. 

She  continued  to  pass  membrane  for  several  months ;  then  the 
trouble  ceased,  and  has  not  returned.  She  now  menstruates  regularly 
and  naturally,  and  has  done  so  for  over  two  years. 

Several  other  cases  might  be  added,  some  showing  failure  of 
treatment,  and  others  where  the  patients  were  really  made  worse  by 
being  treated  for  inflammation  of  the  uterus  which  was  supposed  to 
be  the  cause  of  the  affection,  but  undoubtedly  was  not.  Other  cases 
might  be  given,  also,  in  which  recovery  took  place,  and  after  several 
months  or  years  the  trouble  returned,  but  they  would  add  nothing 
to  the  views  already  expressed  regarding  the  pathology  and  treat- 
ment of  this  affection. 


CHAPTER   XIV. 

LACERATIONS    OF    TUK    CKKVIX    UTKRI    FROM    PARTURITION. 

RiOGARDiXG  this  sul)jcct  Dr.  Tlioinas  Addis  Eiiiinet  says:  "Its 
importance  can  not  be  exaggerated,  since  one  halt'  of  the  ailments 
among  those  who  have  borne  children  are  to  be  attributed  to  lacera- 
tions of  the  cervix." 

This  estimate  of  the  freqnency  and  consequences  of  laceration 
of  the  cervix  uteri  is  quite  sufficient  to  introduce  the  subject  and 
secui'e  for  it  special  attention. 

Sir  James  Y.  Simpson  pointed  out  the  fact  tliat  lacerations  of 
the  cervix  uteri  frequently  occurred,  and  Dr.  Gardiner  also  described 
such  lesions  and  their  results  ;  but  to  Dr.  Emmet  is  due  the  credit 
of  describing  fully  the  pathology  of  lacerations  of  the  cer^^x  and 
their  causative  relations  to  many  other  uterine  diseases.  lie  also 
devised  efficient  surgical  means  for  their  relief.  This  is  certainly 
the  luost  brilliant  of  all  Dr.  Emmet's  achievements. 

The  disturbing  influences  of  this  injury  upon  the  sexual  organs 
and  the  general  health  are  usually  marked,  but  depend  to  some 
extent  upon  the  magnitude  and  location  of  the  laceration.  The  first 
effect  noticed  is  to  retard  recovery  after  confinement.  The  lacera- 
tion exposes  raw  surfaces  to  the  lochial  discharges  which,  when 
these  are  decomposing  and  otfensive,  may  give  rise  to  sei)tica>mia. 
Even  where  this  does  not  occur  the  injury  interrupts,  more  or  less, 
the  process  of  involution  and  produces  all  the  troubles  Avhich  usu- 
ally follow  therefrom. 

There  is  more  or  less  inflammatory  action  set  up  in  the  jiarts, 
and  the  efforts  at  healing  the  laceration  develop  mucii  scar  tissue 
and  not  unfrequently  enlargement  and  hardening  of  the  parts  from 
areolar  hyperplasia.  The  scar  tissue  thus  formed  and  the  sclerosed 
tissues  beneath  and  around  the  scars  are  often  tender  and  painful. 
All  this  proves  to  he  a  source  of  local  irritation,  and  sometimes 
causes  much  general  disturbance  throng] i  reflex  action.     The  inflam- 


LACERATIONS  OF  THE  CERVIX  UTERI  FROM  PARTURITION.  243 

inatory  action  wliicli  immediately  follows  the  injury  does  not  entirely 
subside  when  cicatrization  is  complete.  The  iiitlammation  in  the 
cervical  mucous  membrane  lingers  there,  and  hence  old  lacerations 
are  generally  accompanied  with  marked  catarrh  of  the  cervical  mem- 
brane. This  is  kept  up  and  often  aggravated  by  the  eversion  or 
rolling  outward  of  the  divided  walls  of  the  cervix,  which  exjjoses 
the  cervical  mucous  membrane  to  friction  and  the  acid  secretions  of 
the  vagina.  Therefore,  the  cervical  endometritis  accompanying 
lacerations  has  no  natural  tendency  to  disappear.  It  is  also  rebel- 
lious to  treatment,  and  finally,  if  it  is  subdued,  it  soon  returns  unless 
the  original  injury  is  repaired.  In  lacerations  of  long  standing,  and 
especially  those  that  have  been  treated  by  caustics,  the  mucous  folli- 
cles become  closed  and  distended,  assuming  the  form  of  small  cysts. 
The  presence  of  these  distended  cysts  increases  the  size  of  the  cer- 
vix and  gives  an  irregular  outline  to  the  surfaces  under  which  they 
are  situated.  By  pressure  they  cause  absorption  of  the  tissues  of  the 
cervix,  so  that  when  they  are  punctured  or  ruptured  and  their  con- 
tents are  evacuated  the  cervix  becomes  diminished  below  the  original 
size. 

The  several  forms  of  laceration  of  the  cervix  uteri  most  fre- 
quently seen  in  practice  are  : 

1.  Lateral  lacerations  of  one  or  both  its  walls. 

2.  Antero-posterior  laceration  ;  usually  found  in  the  posterior 
wall,  but  occasionally  involving  both. 

3.  Multiple  lacerations,  usually  three  in  number,  but  occasionally 
more. 

4.  Incomplete  lacerations,  in  which  the  solution  of  continuity 
extends  from  within  outward  through  the  mucous  membrane  and 
muscular  walls  of  the  cervix,  but  not  through  the  mucous  membrane 
of  the  vagina.  This  form  of  injury  is  generally  bilateral,  but  occa- 
sionally the  lacerations  are  multiple,  involving  the  two  walls  laterally 
and  the  posterior  and  anterior  walls  also. 

Sometimes  two  of  these  forms  of  injury  are  found  together,  as, 
for  example,  a  complete  bilateral  laceration  and  an  incomplete  lacer- 
ation of  the  anterior  wall  of  the  cervix. 

The  first,  and  by  far  the  most  common  of  these  injuries,  lateral 
laceration,  presents  several  varieties.  The  bilateral  laceration,  in  its 
typical  form,  divides  the  cervix  into  two  equal  parts,  and  extends  up 
to  the  vaginal  junction. 

As  seen  at  times,  the  laceration  is  superficial,  extending  not  more 
than  half  way  up  to  the  vaginal  junction ;  again,  the  laceration  may 
extend  on  one  side  up  above  the  vaginal  junction,  while  on  the  other 


244 


DISEASES   OF   WOMEN. 


it  is  much  less  exteusive.     In  other  cases  the  liilatcnil  laceration 
divides  the  cervix  into  two  nnc<|ual  parts,  the  anterior  portion  usu- 
ally being  the  larger 
(Fiir.  10.')). 

The  morbid  states 
of  the  cervix  uteri 
which  accom])any 
this  form  of  injury 
and  are  caused  by  it 
vary  i^reatly.  In  the 
simi)lest  forms  the 
cervix,  in  the  aggre- 
«j:ate,  is  not  much  en- 
larged ;  the  divided 
halves  rest  nearly  to- 
gether, and  protect 
the  mucous  mem- 
brane of  the  cervi- 
cal canal.  Under 
these  circumstances 
a  slight  hyperaemia 
of  the  cervical  mu- 
cous membrane  and  a  slight  leucorrhoea  are  all  the  lesions  present  in 
many  cases.     Even  these  are  not  always  found. 

In  other  cases  the  halves  of  the  cervix  are  widely  separated. 
The  mucous  membrane  of  the  canal  is  everted,  and  is  generally  de- 
nuded of  its  epithelium,  markedly  congested,  often  thickened  and 
irreo;u]ar,  and  covered  ^vith  a  profuse  leucorrhoeal  discharge.  In  still 
other  cases  there  is,  in 
addition  to  the  above 
eversion,  a  marked  liy- 
perplasia  of  all  the  tis- 
sues, especially  on  the 
inner  surfaces.  The 
new  tissue  fills  in  the 
space  between  the 
halves  of  the  cervix,  so 
that  the  opposite  sides 
of  the  laceration  can 
not  be  brought  togeth- 
er (Fig  100). 

This    superabund- 


FiG.  105. — Bilateral  laceration ;  unequal  division  of  the 
cervix. 


i 


Fig.  106.- 


-Bilateral  laceration,  with  thickening  of  the 
everted  lips. 


LACERATIONS  OF  THE  CERVIX  UTERI  FROM  PARTURITION.    245 


Fig.  lt)7. — Extensive  multiple  lacerations. 


ant  tissue  is  produced  by  arrest  of  involution  and  areolar  hyperplasia. 
The  tissue  is  denser  than  norinal,  and,  in  fact,  presents  a  true  sclerosis. 

Lacerations  of  the  an- 
tero  -  posterior  walls,  while 
they  are  said  by  Emmet 
to  occur  frequently,  are 
comparatively  less  often 
seen,  because  they  generally 
heal  promptly  and  com- 
])letely  of  their  own  accord. 
Where  they  are  found,  they 
are  generally  complicated 
■svith  all  the  lesions  de- 
scribed in  connection  with 
lateral  injuries. 

Multiple  lacerations  vary 
greatly  in  number  and  ex- 
tent. A  trilateral  laceration 
is  most  frequently  met  with. 
The  cervix  is  usually  di- 
vided into  three  unequal  parts,  as  seen  in  Fig.  107. 

This  may  be  called  a  complete  multiple  laceration,  because  all 
the  tissues  of  the  cervix  are 
divided.  There  is  another 
form  of  this  injury  in  which 
there  are  a  number  of  lacer- 
ations which  extend  from 
within  outward,  but  do  not 
involve  the  vaginal  mucous 
membrane  (Fig.  108). 

The  lateral  incomplete  lac- 
eration may  be  unilateral  or 
bilateral.  Generally,  both 
walls  are  divided  from  within 
outward  to  the  outer  mucous 
coat.  This  injury  is  over- 
looked quite  often  by  gynecol- 
ogists. At  least,  I  infer  this 
from  the  fact  that  Dr.  Em- 
met is  the  only  writer  of  all 
those   whose   works    I    have 

consulted  M'ho  mentions  it.  Fm.  lOS.— Multiple  incomplete  lacerations 


g 

m. 

w^% 

I^^Bh^,;.  lo 

1 

24G 


DISEASES   OF    WOMEN. 


Fig.  109. — Incomplete  bilateral  laceration. 


It  is  usually  described  as  a  patulous  or  dilated  eoudition  of  the 
cervix,  and  to  the  touch  aud  iuspection  it  appears  to  be  so,  but  a 
careful  exaniiuation  shows  that  the  cervix  is  divided  into  two  parts 

that  are  he]<l  tof.'ether  by  the 
outer  coat,  or  mucous  membrane. 
Fig.  109  shows  the  lesion. 

This  lesi(jn  can  be  most  con- 
veniently demonstrated  by  pair- 
ing the  uterine  sound  into  the 
cervical  canal,  and  then  carrying 
it  outward  in  the  line  of  the 
laceration,  when  it  will  become 
apparent  that  the  outer  coat  of 
the  cervical  wall  is  all  that  re- 
mains intact.  There  is  usually 
no  e version  of  the  mucous  mem- 
brane, but  almost  always  there 
is  a  marked  catarrh  of  this  membrane,  which  is  peculiarly  resistant 
to  treatment.  In  a  number  of  these  cases  I  have  found  enlargement 
of  the  anterior  half  of  the  cervix  which  gave  a  crescentic  appearance 
to  the  OS  externum.  Fig.  111. 

Causation.  —  Laceration  of 
the  cervix  is  usually  caused  by 
parturition,  either  natural  or  in- 
stiiimental.  In  a  great  majori- 
ty of  first  labors  the  cervix  is 
injured  to  some  extent,  but  in 
many  the  laceration  either  unites 
or,  being  very  superficial,  gives 
no  trouble  and  passes  unnoticed. 
Certain  conditions  of  the  tissues 
of  the  cervix  predispose  to  lac- 
eration. Irregular  development 
of  the  cervix  either  before  or 
during  pregnancy,  in  which  one 
wall  is  thicker  than  the  other ; 
induration  from  previous  dis- 
ease, which  lessens  the  elasticity 

of  the  tissues ;  and  a  softened  oedematous  condition  of  the  cen'ix, 
produced  by  pressure  in  tedious  labors — all  these  favor  laceration. 

In  abnormal  labors  requiring  manual  and  instrumental  aid  be- 
fore the  cervix  is  dilated  there  is  additional  liability  to  injury,  and 


^^ 

VP 

jMP^ 

i« 

wmA  ■ 

^^K^frf  V''     ""f. 

f 

Fig.  110. — Tlic  incomplete  bilateral  lacera- 
tion shown  in  Fig.  lO'J,  as  seen  b}'  sec- 
tion of  the  cervi.x. 


LACERATIONS  OF  THE  CERVIX  UTERI  FROM  PARTURITION.  24Y 


this  frequently  occurs ;  but  it  is  also  a  fact  that  lacerations  often  take 
place  in  perfectly  easy  and  natural  labors.  Indeed,  it  appears  that 
in  easy  and  rapid  ]a1)or  lacer- 
ations are  veiy  hkely  to  oc- 
cur, such  frequently  showing 
tliat  precipitate  delivery  is  a 
cause  of  this  accident.  Dr, 
Emmet  states  in  his  book 
that  he  has  seen  laceration 
of    the    cervix   in   cases   of 


Fig.  111. — Crescentic  laceration. 


criminal  abortion.  I  have 
never  seen  laceration  of  the 
cervix  after  abortion  from 
any  cause  at  or  before  the 
third  month  of  gestation. 
There  is  a  condition  of  en- 
largement of  the  cervix  with 
eversion  of  the  mucous  mem- 
brane of  the  cervical  canal 
which  presents  all  the  phys- 
ical signs  of  a  superficial 
bilateral  laceration,  and  this 

I  have  seen  aiter  abortion  in  the  first  pregnancy,  but  T  have  also  seen 
the  same  condition  in  the  virgin  uterus.  This  affection  is  described 
under  the  head  of  cervical  endometritis,  and,  therefore,  need  not  be 
discussed  here. 

From  what  has  been  said,  it ,  will  appear  certain  that  this  injury 
can  not  at  all  times  be  prevented  by  any  skill  and  care  on  the  part  of 
the  obstetrician.  This  should  always  be  borne  in  mind  and  freely 
stated  where  the  injury  is  attributed  to  carelessness  on  the  part  of 
the  attendant  during  labor,  a  mistaken  criticism  not  uncommonly 
heard  among  the  laity. 

The  effect  of  this  injury  upon  the  uterus  and  the  general  health 
of  the  patient,  together  with  the  symptoms  and  physical  signs,  will  be 
Ijrought  out  in  full  in  the  histories  ofi  llustrative  cases  which  follow. 

The  treatment  of  this  injury  includes  the  primary  and  secondary 
management.  It  has  been  suggested  that  when  the  injury  takes 
place  the  laceration  should  be  immediately  closid  with  sutures,  but 
this  is  impracticable.  First,  because  it  is  impossible  to  fully  estimate 
the  extent  of  a  laceration  in  the  relaxed  condition  of  the  cervix  im- 
mediately after  delivery ;  and,  secondly,  the  difficulty  of  accurate- 
ly ad  justing  sutures  under  the  circumstances  would  subject  the  pa- 


248  DISEASES   OF    WOMEX. 

tioiit  to  exposure,  wliich  is  unwarranted.  Besides  this,  tlie  intro- 
duction of  sutures  and  the  disturhaiiee  of  the  tissues  necessary  to 
their  introduction  wouhl  tt-nd  to  interfere  with  spontaneous  union, 
a  favorable  termination  not  infreiiuently  attained.  The  priniarv 
treatment  then  must  be  limited  to  the  usual  means  employed 
by  the  competent  obstetrician  to  secure  normal  involution  of  the 
pelvic  organs.  The  secondary  treatment  should  end)race  three 
objects  :  First,  to  overcome  the  consecpiences  of  the  injury  ;  sec- 
ond, to  improve  the  nutrition  of  the  parts  injured,  and  thus  pre- 
pare them  for  the  third  step,  tlie  ro]")air  of  the  laceration  by  surgical 
means. 

When  an  improvement  in  the  condition  of  the  tissues  of  the 
uterus  is  attained,  the  general  health  of  the  patient  is  usually  bene- 
fited by  securing  the  best  conditions  for  success  in  the  operation 
for  restoring  the  laceration.  In  order  to  do  this  it  is  necessary  to 
overcome  as  far  as  can  be  the  endometritis  which  usually  accompa- 
nies the  injury.  The  means  used  for  this  purpose  sometimes  suc- 
ceed in  reheving  the  subinvolution  which  usually  is  present  in  those 
cases.  AVliere  there  is  much  enlargement  of  the  cervix  from  areolar 
hyperplasia,  which  makes  it  impossible  to  bring  the  divided  edges 
together,  and  all  ordinary  treatment  fails  to  reduce  this  enlargement, 
it  is  sometimes  necessary  as  a  preparatory  measure  to  remove  a  por- 
tion of  the  tissue  on  the  inner  sides  of  the  divided  halves  of  the  cer- 
vix and  allow  the  parts  to  heal  before  perfonniug  the  final  opera- 
tion. This  I  have  usually  accomplished  by  taking  out  a  section  on 
each  inner  side  of  the  halves  and  bringing  them  together  with  a 
couple  of  sutures.  These  are  left  in  place  for  a  week  or  two,  and  in 
the  mean  time  the  hot-water  douche  should  be  used,  and  such  local 
applications  as  may  be  necessary  to  relieve  catarrh  or  hyperremia. 
The  sutures  are  then  removed,  and  after  a  few  weeks  the  operation 
for  the  restoration  of  the  cervix  is  performed.  When  there  are  a 
number  of  cysts  in  the  cervix  (a  condition  known  as  cystic  degenera- 
tion) they  should  all  be  opened  and  evacuated.  Sometimes  the 
everted  mucous  membrane  becomes  very  much  thickened,  and  pre- 
sents a  granular  or  papilloma tous-looking  surface.  When  such  is  the 
case,  it  is  best  to  trim  off  the  more  prominent  points  on  the  surface, 
and  subsequently  make  such  a])plication  as  will  reduce  the  thicken- 
ing and  vascularit}'  of  the  membrane. 

It  has  been  suggested  by  some  that  whenever  there  is  a  laceration 
it  should  be  at  once  restored.  Such  authorities  are  of  the  opinion 
that  if  the  0])eration  is  successful  the  other  pathological  lesions  which 
were  caused  originally  by  it  will  disappear  eventually.     This  is  not 


LACERATIONS  OF  THE  CERVIX  UTERI  FROM  PARTURITION.  249 

by  any  incan.s  to  be  relied  upon,  and  I  much  prefer  to  remove,  as  far 
as  possible,  all  local  complications  before  operating. 

The  objects  to  be  obtained  by  tlie  o[)eration  are  to  remove  tlie 
scar  tissue  formed  by  the  healing  of  the  ununited  edges  of  the  lacer- 
ation, and  thereby  relieve  the  pain  and  reflex  disturbances  which 
it  may  have  given  rise  to,  and  also  to  close  in  the  mucous  mem- 
brane and  protect  it  from  further  irritation.  There  is  still  an- 
other important  benefit  gained  by  the  o])eration — viz.,  when  the 
uterus  is  larger  than  normal,  owing  to  subinvolution,  a  marked 
reduction  in  its  size  will  follow  after  this  o|3eration.  I  beheve 
that  the  completion  of  involution  generally  follows  successful  res- 
toration of  the  cervix,  excepting  in  those  who  have  had  puei'peral 
metritis. 

In  restoring  the  cervix  I  frequently  operate  without  anesthetizing 
the  patient.  The  pain  of  the  operation  is  trivial  compared  with  the 
distress  from  the  after-effects  of  an  ansesthetic.  And  the  chances 
of  a  good  result  are  increased  by  avoiding  that  disturbance  of  the 
sutures  caused  by  the  vomiting  which  frequently  follows  the  use  of 
ether  or  chloroform. 

The  operation  for  the  restoration  of  the  cervix  uteri  must  vary 
a  little  in  detail  according  to  the  nature  of  each  form  of  injury, 
but  the  operation,  as  performed  on  the  bilateral,  uncomplicated 
form  of  laceration,  illustrates  in  the  most  perfect  way  the  mech- 
anism and  details  of  the  operation.  I  will,  therefore,  describe 
the  operation  in  this  form  of  laceration,  and  give  cases  the  histo- 
ries of  which  will  illustrate  the  necessary  modifications  in  the  other 
forms. 

The  operation  is  performed  as  follows :  The  patient  is  placed 
upon  the  left  side,  and  a  Siras's  speculum  introduced  and  held  by 
a  trained  nurse  or  assistant.  A  tenaculum  forceps,  curved  upon  the 
flat  side,  is  fixed  in  the  anterior  half  of  the  cervix,  at  the  point  which 
makes  the  lip  of  the  os  externum.  The  posterior  half  of  the  cervix 
is  seized  in  the  same  way  with  a  similar  forceps,  and  the  operator, 
taking  a  forceps  in  each  hand,  brings  the  two  flaps  together,  in 
order  to  see  exactly  where  the  parts  are  to  be  united.  The  forceps 
which  holds  the  anterior  flap  is  then  given  to  an  assistant,  while 
the  one  attached  to  the  posterior  flap  is  held  in  the  left  hand  of  the 
operator,  and  the  surfaces  are  denuded  by  the  hawk-bill  scissors.  Fig. 
112. 

The  points  of  the  scissors  are  made  to  seize  the  angle  formed  by 
the  junction  of  the  two  flaps  as  far  up  as  appears  necessary  to  denude 
them.     The  flaps  are  brought  together  by  the  aid  of  the  forceps  on 


250 


DISEASES   iH'    WOMEN. 


each  side,  so  as  to  bring-  the  tissues  more  withiu  the  grasp  of  the 
scissors. 

The  blades  of  the  scissors  are  then  closed,  and  a  strip  is  removed 
from  above  downward  on  each  tiap.     The   other  side  is  treated  in 


Fig.  112. —  Ilawk-bill  .•scissors. 

the  same  way,  and  the  most  important  part  of  the  denudation  is  com- 
pleted. It  frequently  hajipens  that  a  jjortion  of  the  tissue  to  be  so 
removed  escapes  from  the  scissors  at  the  lower  portion  of  the  flaps 
on  one  or  both  sides ;  but  when  this  happens,  the  denudation  is 
easily  completed  with  the  ordinary  curved  scissors.  If  the  curved 
scissors  only  are  used,  much  difficulty  is  experienced  in  vivifying 
the  upper  angles  of  the  laceration,  but  with  the  hawk-bill  scissors 
this  portion  of  the  operation  can  be  accomplished  accurately  and 
with  facility.  The  hawk-bill  scissors,  while  saving  time  and  trouble, 
give  smoother  surfaces  for  coaptation  than  can  be  otherwise  ob- 
tained. A  faithful  trial  of  both  methods  by  myself,  and  observa- 
tions of  the  old  method  as  practiced  by  the  most  expert  surgeons 
convince  me  of  this  fact.  It  has  been  said  that  all  the  cicatricial 
tissue  can  not  be  removed  with  the  hawk-bill  scissors.  In  regard  to 
that,  I  can  say  that  I  have  always  succeeded  in  removing  all  that 
was  necessary  to  secure  good  union  and  satisfactory  ultimate  results. 
Fig.  113,  colored  plate,  shows  the  two  denuded  sui-faces  on  each  side 
of  the  laceration  and  the  strip  of  the  mucous  membrane  between. 
The  needles  used  are  triangular  and  pointed.  Three  lengths  are 
convenient  to  have,  but  the  medium  one  can  be  made  to  answer  for 

all.     The   shape   and    length   of 
these  are  shown  in  Fig.  114. 

The  needle-forceps  described 
in  connection  with  the  operation 
for  restoration  of  the  pelvic  Hoor 
is  used  for  this  ojicration. 

The  sutures  are  introduced  in 
the  following  manner:  The  nee- 
dle is  placed  in  that  groove  of  the 
Fig.  114.— Triangular  needles.  needle  -  forceps   which   will   give 


^ 

2 

3 

4 

5 

6 

GEO. 

TIEMANN 

&CU 

' 

■ 

PLATE   III. 

Operation  for  Laceration  of  the  Cervix  Uteri. 

Figure  113.      Page  250. 
Denudation  complete. 

Figure  116.     Page  253. 
The  sutures  in  position. 


Figure  117.     Page  253. 
The  sutures  tied. 


PJ.ATE  III 


FIG. 113 
PAGE  250 


FIG. 116 
PAGE  253. 


FIG.  117 

PAGE  253. 


R.L.D.  DEL 


LACERATIONS  OF  THE  CERVIX  UTERI  FROM  PARTURITION.    251 

the  desired  angle,  and  is  held  immovable  there,  while  the  operator 
grasps  the  handle  and  closes  the  catch.  The  needle  is  then  ])assed 
into  the  tissue,  and  left  there  while  the  forceps  is  unclasped  and 
reversed.  Its  other  end  is  then  used  to  grasp  the  point  of  the 
needle  and  draw  it  through.  The  first  two  sutures  are  introduced 
at  the  lower  end  of  the  Haps,  at  ^joints  corresponding  to  the  sides 
of  the  08  internum.  In  some  cases,  when  the  parts  do  not  come 
together  easily,  it  is  well  to  introduce  tirst  a  suture  on  each  side  at 
the  u])per  end  of  the  wound,  and  then  the  two  lower  ones.  AVhile 
introducing  the  first  two  sutures  the  parts  are  held  by  the  tenaculum 
forceps,  which  were  used  during  denudation.  As  each  suture  is 
introduced,  the  ends  are  united  by  passing  one  around  the  other  in 
a  loop-knot.     This  keeps  the  sutures  from  being  tangled. 

The  tenaculnni  forceps  is  then  removed,  and,  while  an  assistant 
steadies  the  cervix  l)y  holding  the  ends  of  the  iirst  sutures,  the  others 
are  introduced,  a  tenaculum  being  used  to  make  counter-pressure 
while  the  needle  is  passed. 

The  sutures  are  tied  as  follows :  One  or  two  turns  of  the  ends 
are  made  to  form  the  first  half  of  the  knot,  the  assistant  takes  hold 
of  one  end,  the  other  is  passed  through  the  loop  of  a  counter-pressure 
instrument,  and  then  seized  by  the  left  hand  of  the  operator.  Trac- 
tion is  then  made  on  both  ends  of  the  suture,  and,  at  the  same  time, 
the  loop  of  the  instrument  is  pushed  down  along  the  thread  to  make 
the  knot  slip  to  its  destination.  Repeating  this  manoeuvre  completes 
the  knot.  The  instrument  used  is  about  the  size  and  shape  of  an 
ordinary  Sims's  tenaculum,  but,  in  place  of  having  a  hook-point,  it 
terminates  in  a  ring  (Fig.  115). 


^t=^      -^G^TIEMANN    ScCO. 


Fig.  115. — Iiing-tenaculura  or  counter-pressure  instrument. 

By  this  method  the  sutures  can  be  tied  about  as  easily  and  rap- 
idly in  the  cavity  of  the  vagina  as  ujjon  a  free  surface.  The  ends  of 
the  sutures  are  then  cut  off,  and  a  small  tampon  of  well-dressed  flax, 
saturated  with  pine  tar  (marine  lint),  is  carefully  packed  in,  first 
around  the  cervix,  and  then  below  it.  This  tampon  maizes  a  good 
antiseptic  dressing.  It  promptly  absorbs  serous  oozing,  and  pre- 
vents anv  motion  of  the  uterus  which  mio-ht  strain  the  sutures.  At 
the  end  of  forty-eight  hours  it  should  be  removed,  and,  if  the  parts 
are  then  in  a  healthj^  condition,  no  further  local  treatment  is  required. 
If  there  is  any  suppuration,  a  fresh  tampon  should  be  introduced, 
and  allowed  to  remain  for  forty-eight  hours  longer. 

From  my  experience  in  a  large  number  of  cases,  I  am  satisfied 


252  DISEASES   OF   WOMEN. 

that  the  use  of  the  tampon  is  a  renal)le  after  treatment  in  this  opeia- 
tion,  and  is  prefei-able  to  the  daily  in  jeetion  of  earbolized  water, 
wliich  80  many  employ. 

The  ])atient  should  rest  in  bi'd,  with  the  privile<re  of  turnin<r 
upon  either  side.  The  bowels  and  bladder  should  be  evacuated  uj)on 
the  i)ed-pan. 

The  sutures  should  ])e  removed  upon  the  ei<j^hth  or  ninth  da\'. 
If  union  is  im])erfect,  the  lower  ones  may  be  left  in  for  two  weeks. 

The  simplicity  of  the  after  treatment  is  its  chief  merit.  Keep- 
ing the  jnitient  i^erfectly  still  in  bed  is  a  great  punishment  to  one  in 
good  general  health,  and  tends  to  prevent  union ;  hence,  giving 
the  patient  the  privilege  of  tossing  about  on  the  bed  is  a  great  com- 
fort. I  am  inclined  to  think  that  I  could  give  the  patient  liberty  to 
get  out  of  bed  to  evacuate  the  bowels  and  urinate,  if  the  tampon  was 
em])loyed  continuously.  As  bearing  on  this  point  1  may  refer  to 
the  case  that  I  operated  upon  in  my  office,  and  sent  home  in  the 
street-cars.  She  made  a  perfect  recover}'.  Another  case  shows  what 
can  be  done  with  impunity.  A  patient  of  Dr.  (xeorge  W.  Baker's, 
a  very  strong,  active  lady,  was  oi)erated  upon  for  a  bilateral  lacera- 
tion in  the  usual  way.  She  refused  to  stay  in  bed,  but  rested  on  the 
sofa,  and  visited  the  water-closet  when  necessary.  Her  menses  came 
on  prematurely  and  profusely.  A  large  coagulum  formed  in  the 
vagina  and  was  passed  while  straining  in  the  water-closet.  Xot  the 
slightest  hope  of  success  was  entertained,  but  on  remoring  the 
sutures  the  results  were  found  satisfactory  in  every  way.  These 
cases  convinced  me  that  the  absolute  quietude  usually  insisted  upon 
is  not  necessary,  and  hence  since  then  I  have  given  more  liberty  of 
action.  Much  discomfort  is  avoided  in  this  way,  and  the  patient 
gets  up  better  and  stronger. 

illustrativf:  cases. 

Typical  Case  of  Bilateral  Uncomplicated  Laceration  of  the  Cervix 
Uteri. — The  patient  M-as  twenty-four  years  of  age,  and  had  her  lii-st 
child  fourteen  months  before  she  was  first  examined.  Her  general 
health  was  fairly  good,  but  she  had  backache  and  profuse  leucor- 
rluea.  A\^alking  or  standing  gave  her  pelvic  tenesmus,  and  she  was 
more  easily  fatigued  than  in  former  years.  She  began  to  menstruate 
ten  months  after  her  confinement,  and  gave  up  nursing  her  child 
when  it  was  a  year  old.  The  menses  were  normal,  but  more  free 
than  formerly,  and  lasted  a  day  longer.  She  was  sterile.  Physical 
examination  showed  that  the  uterus  was  a  little  larger  than  it  usually 
is  in  a  person  of  her  size.     The  cervical  mucous  membrane  was 


LACERATIONS  OF  TIIK  CERVIX  UTERI  FROM  PARTURITION.  253 

liyperaitnic,  and  denuded  of  epithelium  in  ccrtuiii  [)lii(;es.  Tliere  was 
a  profuse  leucorrhoui. 

The  cervical  canal  was  cleared  of  the  leucoiTli(cal  discharge,  and 
an  a{)plication  of  equal  parts  of  tincture  of  iodine  and  carbolic  acid 
was  made.  This  was  repeated  at  the  end  of  a  week  and  after  the 
succeeding  menstruation.  The  cervix  was  restored  in  the  way  al- 
ready descril)ed  without  using  an  anaesthetic. 

Figs.  IK)  and  117,  colored  plate,  show  the  cervix  with  the  sutures 
in  position.  A  marine-lint  tampon  was  used  and  kept  in  position 
for  forty-eight  hours.  No  after  treatment  was  needed.  The  sutures 
were  removed  on  the  tentli  day,  and  the  union  was  complete.  Ihe 
patient  was  kept  in  bed  two  weeks  in  all,  and  during  that  time  was 
given  a  good,  generous  diet,  and  her  bowels  were  moved  daily.  She 
had  no  pain  during  her  I'est  in  bed,  and,  although  weak  when  she 
first  tried  to  walk,  she  soon  regained  her  strength.  After  the  re- 
moval of  the  sutures  a  vaginal  douche  of  borax  and  water  was  used 
up  to  the  time  of  the  next  menstrual  period.  Thi'ee  months  after 
the  operation  she  M'as  free  from  all  her  former  symptoms.  The 
cervix  then  appeared  like  that  of  an  imparous  uterus. 

Bilateral  Laceration  complicated  with  Enlargement  of  the  Cervix 
from  Hyperplasia. — This  patient  had  her  only  child  when  she  was 
twenty-six  years  old.  Her  labor  was  tedious,  but  otherwise  normal. 
From  the  time  of  her  confinemeut  until  I  first  saw  her,  four  years 
afterward,  she  had  not  been  well.  She  suffered  from  backache,  pel- 
vic tenesmus,  and  profuse  leucorrhoea.  Her  general  health,  which 
was  formerly  very  good,  became  impaired.  The  appearance  of  the 
cervix  when  first  seen  is  shown  by  Fig.  106. 

It  was  impossible  to  bring  together  the  edges  of  the  os  exter- 
num, owing  to  the  enlargement  of  the  halves  of  the  cervix.  Consti- 
tutional treatment  was  employed,  and  the  hot-water  douche  and 
tincture  of  iodine  used  locally,  but  at  the  end  of  two  months  there 
was  only  a  slight  improvement  in  the  condition  of  the  cervix.  A  pre- 
liminary operation  was  then  performed  as  follows:  A  crescentic- 
shaped  piece  of  tissue  was  removed  from  the  inner  side  of  each 
half  of  the  cervix  sufiiciently  deep  to  j^ermit  the  halves  to  be 
brought  together  with  very  little  traction.  Fig.  118  shows  the  por- 
tions removed,  the  dark  lines  indicate  the  lines  of  incision.  Two 
sutures,  one  on  each  side  of  the  os  externum,  were  introduced  to 
hold  the  parts  together  while  healing  Avas  going  on.     Figs.  119  and 

120  show  the  parts  brought  together  with  the  sutures,  and  Figs. 

121  and  122  show  a  different  method  of  doing  the  same  operation. 
iJefore  tying  the  sutures  a  piece  of  muslin  saturated  with  wax  was 


25-t 


DISEASES   OF   ^VOMEN. 


placed    bc'twc'C'ii  tlie  luilves    of    the  cervix,  and  left  there  for  four 
days  to  keep  the  coajjtated  parts  from  meeting.     The  sutures  were 


UJ 


Figs, 


Fig.  122. 
Vnothcr  method  of  closinj 
gap. 


the 


Fio.  118.  Fig.  119.  Fio.  120. 

Fig.  118.  Removal  of  crescentic  shaped  piece  (seen  in  section)  when  the  everted  lips  are 

thickened.     Figs.  119  and  120.  Method  of  bringing  the  sides  of  the  sections  together. 

removed  at  the  end  l)f  two  weeks,  wlien  it  was  found  that  tlie  ])arts 
where  the  exscctions   were  made   had    nearly  healed  over.     Three 

weeks  afterward  the  cervix 
was  restored  in  the  usual 
way,  and  good  union  was 
obtained,  and  the  patient 
subsequently  recovered. 

In  cases  like  this  1  have 
sometimes  removed  the  re- 
dundant tissue  of  tlie  cer- 
vix at  the  time  of  perform- 
ing the  final  operation  for 
the  restoration  of  the  cervix.  "Wlien  this  ic  done,  it  is  necessary  to 
keep  a  plug  in  the  cervical  canal  during  the  healing  process  in  order 
to  prevent  the  vivified  portions  from  uniting. 

I  much  prefer  to  do  the  preliminary  operation,  believing  that  I 
can  get  better  results  by  so  doing. 

Laceration  of  the  Posterior  Wall  of  the  Cervix  Uteri,  complicated 
with  Ealargement  of  the  Cervix  and  Cystic  Degeneration  of  the  Mucous 
Membrane. — The  patient  was  lirst  seen  when  thirty-foui'  years  of  age, 
and  had  been  married  thirteen  years.  The  injury  of  the  cervix  oc- 
curred twelve  years  before,  when  she  had  her  only  child.  She  got 
up  from  her  confinement  with  leucorrlioea,  backache,  and  pelvic 
tenesmus,  and  continued  to  suffer  from  these  for  about  one  year, 
when,  becoming  tired  of  being  told  that  her  pelvic  symptoms  would 
disappear  when  she  gained  her  strength,  she  consulted  another  phy- 
sician. Local  treatment  w^as  then  employed  with  benefit,  but  it 
proved  to  be  temporary.  The  lencorrluea  and  other  symptoms  re- 
turned in  an  aggravated  form.  She  continued  in  this  way,  getting  a 
little  temporary  relief  from  treatment  and  again  going  uncared  for. 


LACERATIONS  OF  THE  CERVIX  UTERI  FROM  PARTURITION.  255 

ni)  to  the  time  that  slie  came  uuder  my  care.  For  three  months 
she  was  ti'catecl  for  cystic  degeneration,  catarrh,  and  hypertro{)liy  of 
the  cervix.  Tiie  latter  appeared  to  be  dne  to  imperfect  involution 
and  hyperplasia  combined.  The  laceration  extended  up  to  the  vagi- 
nal junction,  and  there  were  erosion  and  eversion,  but  not  to  any 
great  extent.  In  restoring  the  cervix,  its  sides  were  seized  with  the 
tenaculum  forceps,  and  the  upper  angle  of  the  laceration  vivified 
with  the  hawk-bill  scissors.  The  denudation  was  carried  down- 
ward to  the  OS  externum  with  the  curved  scissors.  The  introduc- 
tion of  the  sutures  and  the  after-treatment  were  conducted  as 
usual.  The  union  was  satisfactory  in  every  way.  There  was  no 
return  of  the  former  symptoms,  and  she  was  classed  among  the  suc- 
cessful cases,  although  she  remained  sterile  without  any  apparent 
cause  for  it. 

Multiple  Laceration  of  the  Cervix. — A  large,  muscular  lady  had  her 
first  child  when  she  was  twenty-six  years  old.  Her  labor  was  tedious, 
the  membranes  rupturing  before  the  cervix  was  fully  dilated.  Man- 
ual dilatation  was  resorted  to,  and  the  forceps  used  to  deliver  before 
the  head  had  fully  descended  into  the  pelvis.  This  much  of  the 
history  was  obtained  from  the  physician  who  attended  her  in  confine- 
ment. Four  years  subsequently  I  first  examined  her  and  found  a 
multiple  laceration  of  the  cervix.  The  irregular  nodulated  state  of 
the  cervix  and  its  density  to  the  touch  suggested  the  thought  that 
there  might  be  malignant  disease  present.  This  suspicion  was  still 
further  aroused  by  a  speculum  examination,  which  revealed  a  profuse 
leucorrhoea  and  a  rough,  vascular,  papillomatous  state  of  the  mucous 
membrane.  The  fact  that  the  parts  improved  promptly  on  treat- 
ment settled  the  diagnosis.  The  cervix  was  divided  into  three  un- 
equal parts  (Fig.  108).  For  two  months  she  was  treated  for  the  in- 
flammation of  the  cervix,  and  at  the  end  of  that  time  the  laceration 
of  the  posterior  wall  was  operated  upon  in  the  usual  way.  It  was 
not  necessary  to  anaesthetize  the  patient,  as  the  operation  required 
only  a  short  time  and  was  not  very  painful.  She  was  kept  in  bed 
for  a  week,  and  good  union  was  obtained.  This  left  the  patient 
with  a  simple  bilateral  laceration,  which  was  successfully  operated 
upon  five  weeks  afterward. 

Multiple  Laceration  inconiplete,  complicated  with  Endometritis  Poly- 
posa. — The  patient  was  thirty -seven  years  old,  married  seventeen 
years,  and  had  borne  three  children,  the  youngest  of  whom  was  two 
years  of  age.  It  was  impossible  to  ascertain  when  the  cei-vix  was 
injured.  The  history  showed  that  her  health  began  to  fail  after  the 
birth  of  her  second  child,  and  that  she  broke  down  completely  after 


256  DISEASES  OF    WOMEN. 

her  third  one  was  horn.  When  she  came  under  niy  ohservation  she 
liad  nienorrliagia,  a  poor  appetite,  and  con.stipation.  She  was  ema- 
ciated, very  anaemic,  irritahle,  sleepless,  and  suffered  much  from 
headaches — in  sliort,  was  ])ei'fectly  useless,  and  a  great  sufferer.  She 
had  free  leucorrha^a,  backache,  and  ovarian  j)ain,  which  was  at  times 
quite  annoying. 

The  physical  signs  indicated  that  there  was  a  polypoid  state  of 
the  endometrium.  There  were  four  lacerations  of  the  cervix.  Two 
lateral,  the  largest,  and  one  in  the  anterior  wall  and  another  in  the 
posterior  wall.  These  latter  might  be  called  fissures.  They  did 
not  extend  through  the  whole  of  the  middle  coat  of  the  cervix. 
The  lateral  lacerations  were  complete,  involving  the  entire  wall  of 
the  cervix  for  about  a  quartei"  of  an  inch  below  and  were  incom- 
plete above.  The  fungosities  of  the  endometrium  were  removed 
with  the  curette.  This  relieved  the  menorrhagia  and  improved  the 
general  health  of  the  patient  to  some  extent.  The  restoration  of 
the  cervix  was  effected  by  operating  upon  the  lateral  lacerations  in 
the  prescribed  way.  i.  e.,  lirst  making  complete  lacerations  of  them, 
and  then  viWfying  the  parts  and  closing  them  with  sutures.  The 
antero-posterior  lacerations  or  fissures  were  treated  by  vivifying 
their  sides  as  well  as  could  be  done  before  closing  the  lateral 
ones.  When  the  sutures  were  tightened  in  the  lateral  lacerations 
it  was  found  that  the  traction  apj)eared  to  hold  the  antero-posterior 
lacerations  together.  The  result  proved  that  such  was  the  case. 
There  was  good  union,  and  the  patient  gained  in  strength  rapidly 
and  was  quite  well  at  the  end  of  three  months. 

Typical  Case  of  Bilateral  Incomplete  Laceration  of  the  Cervix 
TTteri. — The  patient,  a  lady  of  excellent  physique,  married  at  thiity- 
one  years  of  age,  and  had  her  first  child  three  years  later.  liei*  labor 
was  tedious  in  the  first  stage,  but  her  recovery  was  without  any 
marked  interruption.  When  her  child  was  twenty  months  old  she 
became  pregnant  again,  and  miscarried  at  the  third  month.  Six 
months  after  her  miscarriage  she  was  first  examined.  She  then 
suffered  from  menorrhagia.  pelvic  tenesnnis,  and  profuse  leucor- 
rhcea,  which  caused  some  general  depression — but  not  to  any  great 
extent.  The  uterus  was  retro  verted,  and  the  cervical  canal  admitted 
the  index-finger  nearly  to  the  internal  os.  The  uterus  was  a  little 
larger  than  normal,  and  its  mucous  membrane  congested  and  irregu- 
lar to  the  touch  of  the  sound. 

The  uterus  was  restored  to  its  position  and  retained  there  with 
a  pessary.  The  canal  of  the  cervix  was  touched  with  tincture  of 
iodine.     This  gave  her  relief  from  tenesmus,  but  did  not  control 


LACERATIONS  OF  THE  CERVIX  UTERI  FROM  PARTURITION.  257 

the  menorrhagia  nor  the  leucorrlioea.  Subsequently  the  cavity  of 
the  uterus  was  cui-etted,  and  carbolic  acid  and  iodine  were  applied 
to  the  canal  of  the  cervix.  From  this  tune  on  the  menses  were  nor- 
mal, but  the  leucorrhoea  returned  again  and  again.  Treatment 
would  arrest  it  for  a  time,  but  it  returned,  and  she  proved  to  be  ster- 
ile. Kestoration  of  the  cei-vix  was  proposed  in  the  hope  that  the 
operation  would  give  her  permanent  relief. 

The  operation  was  performed  as  follows :  Taking  hold  of  the 
anterior  and  posterior  walls  of  the  cer^dx  with  the  tenaculum  for- 
ceps, a  straight  scissors  was  passed  into  the  cervix  half  its  entire 
length,  and  the  mucous  membrane  of  the  vagina  (the  portion  of  the 
cervical  wall  which  escaped  laceration)  was  divided.  The  other  side 
was  treated  in  the  same  way.  The  halves  of  the  cervix  were  drawn 
apart,  so  that  the  extent  of  the  internal  laceration  cotM  be  clearly 
seen,  and  then  the  angle  on  each  side  was  vivified  with  the  hawk- 
bill  scissors.  After  this  there  still  remained  a  little  redundant  vagi- 
nal mucous  membrane  at  the  lower  portion  of  the  cervix,  and  be- 
tween the  vaginal  and  cervical  mucous  membrane  the  site  of  the 
laceration,  the  muscular  walls  remained  modified.  The  redundant 
vaginal  membrane  was  removed  and  the  middle  walls  of  the  cervix 
we're  vivified  with  the  cmwed  scissors.  This  modification  of  the 
method  of  vivifying  the  parts  to  be  united  became  necessary  because 
of  the  lacerations  being  incomplete. 

In  some  cases  of  incomplete  laceration  when  the  cervix  is  large, 
it  is  best  to  divide  the  vaginal  mucous  membrane  first.  By  using 
the  hawk-bill  scissors  a  Y-shaped  piece  can  be  taken  out  on  each  side 
which  completes  the  vivifpng  with  a  single  chp  of  the  scissors  on 
each  side. 

The  sutm-es  were  introduced  and  the  operation  completed  in 
the  usual  way.  The  case  progressed  favorably,  union  was  complete, 
and  there  has  been  no  return  of  the  leucorrhoea  nor  any  of  her  for- 
mer symptoms. 

Incomplete  Laceration  with  Hypertrophy  of  the  Anterior  Half  of  the 
Cervix— The  patient  had  sufiered  from  a  profuse  leucorrhcea  since 
the  birth  of  her  child  five  years  before.  She  had  been  treated  oc- 
casionally, and  derived  only  temporary  relief,  the  symptoms  return- 
ing again  when  treatment  was  suspended.  The  enlargement  of  the 
anterior  half  of  the  cervix  was  confined  mostly  to  the  mucous  mem- 
brane. This  gave  a  crescentic  appearance  to  the  os  externum  (Fig. 
11-2).  The  treatment  consisted  of  exsection  of  the  hypertrophied 
portion  of  the  mucous  membrane  in  the  anterior  wall,  and  when 
the  parts  had  healed  the  laceration  was  operated  on  in  the  same 
18 


258  DISEASES  OF   WOMEN. 

manner  as  in  the  case  of  incomplete  laceration  preceding  this 
one. 

The  exsection  was  made  by  seizing  the  part  to  be  removed  with 
a  tissue  forceps,  and  \dth  a  sli<jhtly-curved  scissors,  clipping  off  the 
whole  of  the  mucous  membrane  on  that  side  up  as  high  as  the  hy- 
pertrophy extended.  There  was  some  bleeding,  but  that  was  very 
easily  controlled  by  packing  the  cervical  canal  with  cotton,  and 
using  a  vaginal  tampon  to  keep'  it  there. 

The  Results  of  the  Surgical  Treatment  of  Lacerations  of  the  Cervix 
Uteri. — There  are  some  points  that  remain  to  be  settled  by  reliable 
observations  regarding  the  results  of  the  surgical  treatment  of  these 
injuries.  More  statistics  by  reliable  observers  are  needed  to  deter- 
mine definitely  all  the  benefits  which  may  be  reasonably  expected 
from  this  form  of  treatment. 

It  may  be  fairly  claimed  that  successful  restoration  of  the  cervix 
will  relieve  the  inflammatory  troubles  of  the  cervix,  including  the 
suffering  from  scar  tissue  in  the  great  majority  of  cases. 

Sterility  due  to  the  injury  of  the  cervix  and  the  consequent  le- 
sions is  cured  in  many  cases. 

Labor  is  not.  as  a  rule,  retarded  by  the  condition  of  the  cervix 
after  the  operation.  JS^or  does  laceration  necessarily  occur  again. 
I  have  been  able  to  compare  the  dilatability  of  the  cer^nx  after 
trachelorraphy  with  that  of  lacerated  cervix  with  scar  tissue,  and  I 
have  found  that  the  results  are  greatly  in  favor  of  those  patients  in 
whom  the  cervix  has  been  restored. 


CHAPTER  XV. 

CICATRICES    OF   THE    CERVIX   UTERI   AND   VAGINA. 

Cicatrices,  the  results  or  products  of  diseased  action  and  inju- 
ries, are  of  pathological  importance  according  to  their  size  and  loca- 
tion. They  derange  the  conditions  of  health  and  comfort  by  the 
tender  and  painful  character  of  scar  tissue,  and  by  its  inelasticity, 
which  interferes  with  the  free  motion  of  the  pelvic  organs.  The 
slow,  persistent  contraction  of  this  abnormal  tissue,  by  which  the 
adjacent  normal  parts  are  united,  causes  pain  by  making  pressure  on 
the  terminal  nerve-fibers.  Tenderness,  also  a  characteristic  of  scar 
tissue,  is  developed  in  the  same  way,  or  perhaps  from  the  excessive 
irritability  or  imperfect  protection  of  the  nerves  found  in  cicatrices. 
This  tenderness  is  most  marked  in  scars  at  or  near  the  introitus 
vaginae,  and  varies  according  to  the  age  of  the  new  tissue.  When 
an  uninterrupted  cicatrix  surrounds  the  cervical  canal,  the  os  ex- 
ternum, or  the  vagina  at  any  point,  stenosis  is  produced,  and  all  the 
derangements  consequent  thereon,  according  to  the  partial  or  com- 
plete development  of  the  stricture. 

Causation.— The  causes  which  lead  to  the  formation  of  cicatrices 
are  familiar  to  all,  and  require  only  to  be  named  in  order  to  recall 
them  for  present  consideration  :  Injuries  during  parturition  suffi- 
cient to  cause  sloughing  or  loss  of  tissue  ;  lacerations  which  heal  over 
without  uniting  the  divided  parts,  or  which  are  united  by  interven- 
ing new  tissue  ;  amputation  of  the  vaginal  portion  of  the  cervix ; 
exseetion  of  a  portion  of  the  vagina,  especially  where  healing  takes 
place  by  granulation  ;  destniction  of  the  mucous  membrane  and  sub- 
jacent structures  by  the  free  use  of  caustics,  and  extensive  ulceration 
either  simple  or  specific.  These  are  the  chief  affections  which  give 
rise  to  the  conditions  now  under  consideration. 

Symptomatology. — The  symptoms  developed  by  cicatrices  are 
pain,  which  is  often  intennittent  or  remittent,  and  is  usually  in- 
creased by  exercise.     When  the  scar  involves  the  circumference  of 


260  DISEASES   OF    WOMEN. 

the  cervix,  aiul  tlie  caliber  of  the  canal  is  reduced  l)elow  tlie  normal 
size,  dysmeuorrhcea  occurs  in  some  cases.  When  the  va<5lna  is  ex- 
tensively involved,  the  functions  of  the  bladder  and  rectum  are  occa- 
sionally (leraii^etl  so  as  to  give  rise  to  fre(|uent  and  ditticult  urination 
and  painful  defecation.  This  is  due,  doubtles.-^,  to  the  tenderness  of 
the  scar  tissue,  and  diminished  mobility  of  the  pai-ts.  For  the  same 
reason,  coition  is  ])ainful,  and  in  some  marked  cases  impossible.  It 
will  be  observed  that  the  same  derangement  of  the  sexual  function 
occurs  in  vaginitis,  vaginismus,  and  in  that  rare  neurotic  affection 
in  which  there  is  extreme  hypenesthesia  without  any  apparent 
change  of  stnicture  or  circulation  to  account  for  it.  In  short,  any 
or  all  of  the  symptoms  caused  by  cicatrices  may  arise  from  other 
pathological  conditions,  such  as  are  f<iund,  for  example,  in  conva- 
lescence from  pelvic  peritonitis  or  cellulitis.  On  that  account  the 
diagnosis  must  be  based  chiefly  on  the  physical  signs.  These  I  may 
briefly  mention.  They  are  the  presence  of  abnormal  tissue,  which 
is  usually  tender,  always  indurated,  less  elastic  than  healthy  parts, 
and  sometimes  lighter  in  color,  and  having  a  smooth  sui-face.  Cica- 
trices of  the  vagina  are  easily  detected  ;  those  of  the  cervix  are  liable 
to  be  confounded  with  sclerosis  and  incipient  malignant  disease. 
The  points  of  distinction  are  the  increase  of  tissue  and  abnormal 
vascularity  found  in  the  latter. 

Knowing  the  evils  which  cicatrices  give  rise  to,  the  first  duty  of 
the  practitioner  is  to  guard  against  their  formation.  This  can  be 
accomplished  to  a  great  extent,  I  am  sure,  by  observing  ceitain  lines 
of  practice.  Lacerations  of  the  pelvic  floor,  occurring  during  nat- 
ural or  artificial  delivery,  should  be  immediately  brought  together 
by  sutures,  when  it  is  possible  to  do  so,  in  place  of  leaving  them  to 
heal  as  best  they  may,  which  is  the  usual  practice.  In  many  such 
cases  the  patient  is  anaesthetized  when  the  injury  is  sustained,  and, 
if  the  obstetrician  has  the  requisite  instruments  at  hand — as  he  ought 
to  have — the  operation  of  closing  such  wounds  with  sutures  is  prac- 
ticable ;  if  such  wounds  can  be  made  to  heal  without  the  interven- 
tion of  much  new  tissue,  the  cicatrices  are  very  unimportant  com- 
pared with  the  large  scars  which  are  sometimes  formed  where  healing 
takes  place  by  granulation. 

In  making  these  statements,  I  am  aware  that  the  ground  taken 
may  be  questioned.  In  opposition  to  this  practice,  it  may  be  said 
that  such  wounds  often  heal  promptly  without  the  aid  of  sutures, 
and  even  when  sutures  are  employed  there  is  no  certainty  that  good 
union  will  take  place.  On  the  other  hand,  it  can  be  fairly  claimed 
that,  if  the  edges  of  a  lacerated  wound  are  held  together,  the  chances 


CICATRICES   OF   THE   CERVIX   UTERI   AND    VAGINA.       261 

of  their  uniting  are  better  than  if  left  alone.  Even  sliould  healing 
take  place  by  granulation,  the  sutures,  preventing  the  wide  separation 
of  the  parts,  will  tend  to  lessen  the  size  of  the  cicatrix.  When  there 
is  so  nnich  to  be  gained  by  good  union,  and  so  much  suffering  en- 
tailed by  bad,  the  use  of  sutures  in  such  cases  is  surely  good  surgery. 

The  formation  of  troublesome  cicatrices  following  the  use  of 
caustics  may  be  prevented  by  carefully  circumscribing  the  space  to 
which  they  are  applied,  and  by  avoiding  their  use  to  an  extent  suf- 
ficient to  cause  destruction  of  the  deeper  structures  of  the  mucous 
membrane.  When  it  is  necessary  to  apply  a  caustic — say  nitric  acid 
— to  the  OS  externum  or  cervical  canal,  a  portion  of  the  membrane 
should  be  left  untouched  if  possible,  so  that  the  eschar,  if  one  is 
formed,  will  not  completely  circumscribe  the  canal.  By  attention 
to  these  points,  cicatrices  may  be  prevented,  or,  if  they  follow,  they 
will  be  less  troublesome  in  character. 

In  amputating  the  cervix,  that  method  of  operating  should  be 
chosen  which  will  secure  the  most  serviceable  stump.  The  flaj)  or 
circular  amputation,  in  which  the  mucous  membrane  is  brought  over 
the  stump  and  held  in  place  by  sutures  according  to  the  methods  of 
Sims  or  Schroeder,  gives  the  most  satisfactory  results,  especially  so 
where  the  parts  heal  promptly.  When  suppuration  occurs,  and  the 
parts  heal  by  granulation,  the  stump  is  less  perfect ;  but  even  then 
it  is  better,  as  a  rule,  than  when  the  stump  is  left  unclosed. 

Treatment. — In  the  treatment  of  cicatrices  the  chief  indications 
are  to  relieve  the  pain  and  tenderness  of  the  parts,  prevent  contrac- 
tions, and,  where  deformities  exist,  to  correct  them.  These  require- 
ments can  be  most  promptly  and  perfectly  fulfilled  by  removing  the 
whole  of  the  cicatrix,  and  bringing  together  the  normal  tissues,  and 
obtaining  as  near  immediate  union  as  possible.  But  this  radical 
treatment  is  only  called  for  in  rare  cases,  and  is  not  always  practica- 
ble, owing  to  the  size,  depth,  and  unfavorable  location  of  the  cica- 
trix. Exsection  should  not  be  undertaken  in  any  case  unless  the 
scar  is  movable  on  the  subjacent  tissue.  It  is  necessary  to  wait 
until  this  mobility  is  established,  which  usually  occurs  sooner  or  later. 
When  the  scar  can  not  be  removed  altogether,  contraction  should 
be  guarded  against  by  preventing  it  from  shortening.  In  oblong 
cicatrices,  contraction  in  width  rarely  gives  trouble,  while  shorten- 
ing causes  deformity.  This  can  often  be  prevented  by  dividing  the 
scar  at  one  or  more  points,  and  then  putting  the  parts  on  the  stretch 
by  the  tampon  or  pessary.  The  divided  edges  thus  held  apart  are 
united  by  intervening  new  tissue,  and  the  scar  is  lengthened,  while 
the  process  of  narrowing  still  continues.    Sometimes  the  contractility 


262  DISEASES   OF   WOMEN. 

of  the  normal  tissues  is  sufficient  to  draw  the  divided  edges  of  the 
sear  apart,  so  that  incising  the  scar  is  all  that  is  necessary. 

When  a  cicatrix  surrounds  the  os  externum,  it  should  he  divided 
on  two  sides,  the  lateral  being  preferable  in  most  cases ;  a  tent  of 
sea-tangle  should  then  be  introduced  and  worn  during  the  process 
of  liealing.  The  tent  should  be  short,  so  as  not  to  enter  the  internal 
OR,  and  it  can  be  held  in  position  by  a  pessary  b}'^  stitching  it  to  the 
walls  of  the  cervix.  The  frequent  use  of  the  sound  or  dilat(jr  will 
answer  the  same  purpose. 

In  the  management  of  cicatrices  of  the  vagina,  very  satisfactory 
results  are  obtained  by  the  treatment  proposed.  After  dividing  the 
cicatrix,  the  parts  are  i)ut  upon  the  stretch  by  the  glass  dilator  em- 
ployed by  Sims  and  others  in  the  treatment  of  atresia  vaginae.  1 
have  also  used  for  the  same  purpose  elm-bark,  made  into  a  roll  of 
the  proper  length  and  thickness,  and  beaten  until  it  is  soft.  It  is 
then  dipped  in  carboUzed  water,  and  introduced  like  a  pessary.  This 
has  the  advantage  of  being  agreeable  to  the  tissues,  and  by  expand- 
ing very  slowly  it  causes  distention,  which  is  easily  borne.  By  en- 
larging the  size  used  from  day  to  day,  the  vagina  can  be  distended 
slowly  and  without  pain.  I  am  satisfied  that  this  metliod  of  treatment 
has  another  advantage,  which  is,  that  by  slow,  continuous  dilatation 
the  normal  portions  of  the  vagina  can  be  developed  so  as  to  compen- 
sate for  the  contraction  of  the  cicatrix  to  a  very  considerable  extent. 

AVhen  there  is  no  considerable  deformity,  and  pain  and  tender- 
ness are  the  only  symptoms,  the  most  marked  relief  will  often  follow 
an  incision  of  the  cicatrix  at  a  number  of  points.  I  have  also  been 
led  to  believe  that  softening  of  the  scar  and  relief  from  pain  were 
obtained  by  the  frequent  application  of  equal  ])arts  of  tincture  of 
opium,  aconite,  and  iodine. 

A  word  might  Ije  said  al)out  complications,  such  as  vaginitis, 
cervical  endometritis,  etc.  They  are  to  be  treated  in  the  usual  way, 
of  course.  I  need  only  add  that,  so  far  as  nay  observations  have  ex- 
tended, it  has  been  found  that  by  relieving  trouble  caused  by  cica- 
trices, recovery  from  accompanying  affections  is  facilitated.  This  is 
as  might  be  expected. 

ILLUSTRATIVE    CASES. 

Scar  Tissue  producing  Stenosis  of  the  Vagina.  Primary  Cause: 
Acute  Inflammation  during  the  Course  of  the  Fever. — A  lady,  thirty 
years  of  age,  large,  Avell  formed,  and  in  general  good  health,  men- 
struated first  at  fifteen  years  of  age,  and  has  continued  to  do  so 
regularly  and  normally  ever  since.     She  has  been  married  twelve 


CICATRICES   OF   THE   CERVIX    UTERI    AND   VAGINA.       263 

years,  and  (hiring  that  time  coition  has  heen  impossible.  Before 
marriage  slie  had  no  symptoms  of  uterine  disease,  but  soon  after  she 
developed  uterine  and  vaginal  leucorrhcea,  which  have  continued  in- 
termittently ever  since.  She  has  also  sulfered  occasionally  from 
backaciie  and  irregular  pains  in  the  pelvis.  Examination  by  the 
touch  revealed  contraction  of  the  whole  vagina,  so  that  the  index- 
finger  could  with  diliiculty  be  introduced,  and  at  the  upper  portion 
there  was  a  stricture  through  which  the  finger  could  not  be  passed. 
In  a  pocket  beyond  the  stricture  the  cervix  uteri  was  subsequently 
found.  The  stricture  was  due  to  scar  tissue,  which  formed  a  circular 
band  about  a  quarter  of  an  inch  wide.  From  this  ring,  extending 
downward,  there  was  another  cicatrix  which  terminated  at  the  re- 
mains of  the  hymen.  There  was  subacute  vaginitis  and  the  papillae 
of  the  mucous  membrane  were  enlarged  and  exceedingly  tender. 
The  examination  caused  intolerable  pain.  At  another  time  an  anges- 
thetic  was  given  and  the  stricture  divided.  The  utenis  was  then 
found  to  be  normal  in  size  and  shape,  but  there  was  a  little  erosion 
about  the  os  externum  and  congestion  of  the  cervical  mucous  mem- 
brane and  hypersecretion. 

Nothing  in  the  history  of  the  case,  nor  in  the  local  lesions,  gave 
any  clew  to  the  cause  of  the  trouble,  but  on  re-examination  it  was 
found  that  when  the  patient  was  a  child  she  had  what  was  called 
t}q3ho-malarial  fever  followed  by  pelvic  inflammation  and  the  forma- 
tion of  abscesses. 

From  this  much  of  the  history  obtained  from  the  patient's 
mother,  I  presumed  that  the  cicatrices  of  the  vagina  were  the  prod- 
ucts of  the  disease  of  her  childhood. 

The  treatment  employed  in  this  case  was  such  as  has  been  de- 
scribed, and  marked  improvement  has  followed.  At  the  end  of  four 
months  after  beginning  the  treatment  the  vagina  admitted  Cusco's 
speculum;  the  tenderness  was  reduced,  but  not  wholly  relieved. 
The  patient  went  to  the  country  for  the  summer,  to  return  in 
October  for  futher  treatment. 

Scar  in  the  Yaginal  Wall  resulting  from  an  Injury  sustained 
during  Labor.— I  was  called  to  see  a  lady  two  months  after  her  con- 
finement with  her  first  child.  I  learned  that  she  had  had  a  tedious 
labor  and  was  delivered  by  forceps.  She  made  a  good  recovery,  ex- 
cept that  when  she  undertook  to  stand  or  walk  she  suffered  from 
sharp  pains  in  the  vagina  and  a  feeling  of  dragging  and  weight, 
especially  on  the  left  side. 

On  examination  I  found  a  recent  cicatrix  on  the  left  side  extend- 
ing from  the  lower  portion  of  the  labium  majus  up  the  vagina  for 


b 


2«]4  DISEASES   OK   WOMEN. 

about  three  inches.  The  sear,  which  wiu^  about  lialf  an  inch  in 
width,  was  quite  tender  to  the  toucli,  and  in  the  center  of  it,  liere 
and  there,  a  few  granuhitions  remained  and  bled  on  being  rougldy 
touched.  The  patient,  although  very  healthy  and  strong,  had  not 
been  able  to  go  up  or  down  stairs  or  leave  the  house  for  two  months 
after  her  continement,  the  time  when  I  saw  her.  iSo  other  uterine 
or  pelvic  disease  could  be  found. 

This  case  shows  the  trouble  which  wounds  of  the  vagina,  sus- 
tained (luring  confinement,  will  cause,  and  it  is  reasonable  to  suppose 
that  if  the  parts  had  been  united  by  sutures  at  the  time  of  injury  a 
more  prompt  recovery  would  have  followed. 

Scar  Tissue  between  the  Posterior  Wall  of  the  Cervix  Uteri  and 
Vagina,  caused  by  Former  Treatment. — This  iauy  was  lifty  years  old, 
and  had  passed  the  menopause  several  years.  Her  health  had  been 
very  good  during  most  of  her  life.  She  had  some  uterine  inflamma- 
tion and  leucorrhoea  after  the  birth  of  her  last  child,  and  was  treated 
with  caustic  a})plications  which  relieved  the  leucorrhoea.  After  this 
she  began  to  have  pelvic  pain  of  a  neuralgic  character,  which  in- 
creased gradually.  This  pain  was  greatly  aggravated  by  exercise. 
The  effect  of  the  local  suffering  and  inability  to  take  active  exercise 
upon  her  nervous  system  was  very  marked. 

A  vaginal  examination  by  the  touch  detected  a  thin  band  of  scar 
tissue  extending  from  the  posterior  wall  of  the  cervix  to  tlie  vaginal 
wall.  The  scar  was  quite  tender,  and  when  touched  with  the  probe 
or  linger  gave  rise  to  the  neuralgic  pain  from  which  she  generally  suf- 
fered. The  patient  was  placed  on  the  side,  and  a  Sims's  speculum 
introduced.  The  cervix  was  caught  with  a  tenaculum  and  drawn 
forward.  This  put  the  scar  tissue  on  the  stretch  and  made  it  promi- 
nent. The  whole  scar  tissue  was  removed  with  one  sweep  of  the 
curved  scissors,  and  the  edges  of  the  mucous  membrane  of  the 
vagina  were  united  with  a  few  catgut  sutures.  The  parts  healed 
without  delay,  and  all  the  local  pain  and  general  disturbances 
promptly  subsided.  The  relief  was  so  prompt,  complete,  and  per- 
manent, that  there  can  be  no  doubt  about  the  scar  tissue  being  the 
whole  cause  of  the  patient's  suffering. 

This  case  is  a  fair  sample  of  a  class,  now  fortunately  diminish- 
ing in  number,  in  whom  scars  are  produced  by  the  use  of  caus- 
tics. The  general  practitioner  nsing  a  Ferguson  s]ieculum  and  a 
swab  in  treating  diseases  of  the  cervix  uteri,  usually  does  very  little 
to  cure  the  disease,  but  much  to  destroy  the  tissue  of  the  cervix  and 
vagina.  The  swab  charged  with  a  strong  caustic  solution  and 
pushed  up  into  the  canal  is  compressed  so  that  the  caustic  runs  down 


CICATRICES   OF   THE    CERVIX   UTERI    AND   VAGINA.       265 

on  the  posterior  wall  of  the  cervix  and  vagina.  While  tlie  diseased 
tissues  get  very  little  of  the  application,  the  normal  tissues  at  that 
point  are  destroyed.  This  is  often  repeated,  and  results  in  forming 
scar  tissue  such  as  that  presented  in  this  case.  Such  results  of  treat- 
ment were  often  seen  years  ago,  and  at  the  present  day  they  are  far 
too  common. 

A  Band  of  Scar  Tissue  just  within  the  Introitus  Vaginae,  and  ex- 
tending across  from  Side  to  Side  of  the  Vagina,  caused  by  Forceps  De- 
livery.— The  patient  was  undersized,  but  a  strong,  healthy  lady. 
She  was  confined  with  her  first  child  five  months  before  I  saw  her. 
Her  ]>hysician  told  me  that  the  child  was  large  in  proportion  to  the 
mother,  and  that  he  was  obliged  to  deliver  with  forceps  while  the 
head  was  high  in  the  pelvis.  In  the  delivery,  much  damage  was 
done  to  the  cervix  and  vagina,  but  the  pelvic  floor  was  not  torn. 
She  recovered  slowly  from  her  labor,  and  continued  to  have  a  dis- 
charge and  pain,  mostly  of  a  neuralgic  character. 

I  found  a  semicircular  band  of  scar  tissue  running  from  the 
ramus  of  the  pubes,  high  up  and  around  the  vagina  to  the  opposite 
side.  The  scar  was  unyielding,  so  that  the  finger  Qould  be  intro- 
duced with  some  difficulty  into  the  vagina.  It  extended  deep  down 
below  the  mucous  membrane  of  the  vagina,  and  at  tlie  upper  ends 
was  fixed  to  the  pubic  bones.  It  appeared  to  me  that  in  the  original 
injury  the  whole  of  the  vaginal  wall,  together  with  the  bulbo-caver- 
nosus  muscles  and  the  anterior  fibers  of  the  levator-ani  muscle  had 
been  torn  away  from  its  attachments  to  the  floor  of  the  pelvis. 

I  have  never  before  nor  since  seen  an  injury  exactly  like  this, 
and  hence  I  do  not  know  positively  how  it  was  produced,  but  pre- 
sume it  occurred  as  I  have  stated.  About  half  an  inch  from  the 
median  line  of  the  posterior  wall  of  the  vagina  the  scar  tissue  was 
divided  on  each  side.  Traction  backward  was  then  made  with  a 
narrow-bladed  Sims's  speculum  which  distended  the  vulva  and  at 
the  same  time  brought  the  ends  of  the  incisions,  which  were  made 
parallel  to  the  axis  of  the  vagina,  together.  The  sides  of  the  incis- 
ions were  held  together  with  sutures.  The  immediate  effect  of  this 
operation  was  to  relieve,  in  a  marked  degree,  the  pains  from  which 
the  patient  had  suffered.  It  also  restored  the  dilatability  of  the 
vulva,  so  that  the  patient  could  resume  her  sexual  duties  when  the 
incisions  had  healed.  She  still  has  pain  and  tenderness,  and  I  pre- 
sume that  there  will  be  contraction  again  which  will  require  further 
treatment. 

The  case  being  a  recent  one,  its  future  history  has  yet  to  be  de- 
veloped. 


CHAPTER  XVI. 


ESr\'ERSION    OF    THE    UTERUS. 


Intersion  may  be  defined  as  a  turning  inside  out  of  the  uterus, 
in  which  its  walls  descend  into  its  cavity.  The  external  surface  l>e- 
coraes  the  internal,  and  the  fundus  uteri,  which  should  be  highest 
in  the  pelvis,  becomes  lowest.  There  are  several  de- 
grees of  inversion,  varying  from  a  mere  depression 
of  a  portion  of  the  uterus,  to  a  complete  inversion. 
In  practice  two  degrees  can  be  made  out,  and  these 
can  be  easily  comprehended  by  a  reference  to  Figs. 
123  and  124. 

In  tiie  first  form  there  is  a  depression  of  one 
side  or  partial  inversion  ;  the  second  form  is  a  com- 
plete inversion.  When  the  vagina  is  also  inverted, 
the  condition  is  known  as  inversion  and  prolapsus. 

This  complication  occurs  as  a  rule  in  the  puer- 
peral state  only.  In  all  cases  of  inversion,  at  least 
at  the  time  when  this  accident  occurs,  enlargement 
and  relaxation  of  tlie  tissues  of  the  uterus  are  found. 
This  is  particularly  so  in  the  puerperal  state,  when  inversion  oc- 
curs most  frequently. 

Sym])toinatolo(j]i. — The  severity  of  the  symptoms  depends  ujjon 
the  extent  of  the  inversion  and  the  sudden- 
ness with  which  it  occurs.  Partial  inversion, 
brought  about  gradually,  may  not  cause  suffi- 
cient disturbance  to  attract  attention.  The 
symptoms  of  shock  are  present  when  the  in- 
version occurs  suddenly,  as  it  does  in  the  puer- 
peral state.  The  shock  and  pain  are  more 
marked,  as  a  rule,  when  the  inversion  is  accom- 
panied with  prolapsus.  In  a  few  recorded  cases, 
the  shock  alone  proved  fatal. 


Fig.  123.— Partial 
inversion  (Thom- 
as). 


If  there  is  great 


Fig.    124. — f'omplcte 
version  (Thomas). 


INVERSION   OF  THE  UTERUS.  267 

hsemorrliage  as  well  as  shock,  the  patient  is  more  likely  to  suc- 
cumb. 

Haemorrhage  occurs  when  the  inversion  is  incomplete  as  well 
as  when  complete,  especially  at  the  time  when  the  accident  takes 
place.  The  presence  of  the  uterus  in  tlie  vagina  causes  disturbance 
of  the  bladder  and  rectum,  by  pressure. 

These  are  the  symptoms  which  occur  in  acute  inversion,  and  if 
the  patient  passes  safely  through  this  stage  then  the  symptoms  of 
chronic  inversion  appear. 

In  complete  inversion  after  the  uterus  has  fully  contracted,  the 
haemorrhage  is  not  profuse,  except  at  the  menstrual  periods,  when 
there  may  be  menorrhagia.  This  is  generally  a  sero-sanguinolent 
discharge  for  the  first  week  or  even  later,  then  the  irritation  may 
cause  congestion,  ulceration,  and  general  inflammation  of  the  vagina 
and  mucous  membrane  of  the  uterus,  and  a  consequent  leucorrhoea 
and  pumlent  discharge. 

If  the  uterus  remain  outside  of  the  vagina  it  usually  becomes 
dry  from  exposure  to  the  air,  but  it  also  becomes  abraded  in  places 
and  finally  ulceration  occurs.  Whether  the  uterus  remain  in  the 
vagina  or  becomes  completely  prolapsed,  the  inflammation,  ulcera- 
tion, h8emorrhage,  and  the  purulent  discharge  which  arise  there- 
from may  break  down  the  general  health  of  the  patient  and  the  case 
terminate  fatally. 

Throughout  all  this  there  is  pelvic  pain  and  tenesmus. 

Physical  Signs. — The  diagnosis  (which  is  not  by  any  means 
easy  in  all  cases)  depends  largely  upon  the  physical  signs.  These 
differ  somewhat  in  recent  cases  and  in  those  of  long  standing. 
When  the  inversion  occurs  after  labor,  the  bimanual  touch  wdll 
reveal  two  very  important  facts.  The  uterus  is  not  found  in  its 
position  behind  the  pubes,  but  occupies  the  pelvic  cavity,  and  can 
be  outlined  in  the  vagina.  By  moving  the  uterus  between  the 
two  hands,  the  fundus  and  body  will  be  found  below  in  the  true 
pelvis,  while  in  place  of  the  fundus  being  found  above,  a  depres- 
sion in  the  uterus  can  be  felt  at  the  superior  strait.  If  the  vagi- 
nal touch  alone  is  relied  upon,  the  condition  will  be  taken  for  the 
coming  placenta.  The  placenta  being  attached  to  the  uterus,  as  it 
usually  is  at  this  time,  obscures  the  uterus,  but  upon  trying  to  re- 
move it  from  the  vagina  by  hooking  down  one  of  its  edges  with  the 
finger,  the  solid  uterus  will  be  found  above  the  placenta,  the  two 
being  united,  but  easily  separated.  While  this  exploration  and  re- 
moval of  the  placenta — if  it  is  present — are  going  on,  the  left  hand 
is  placed  upon  the  abdomen,  and  the  absence  of  the  uterus  above  is 


268  DISEASES   OF   WOMEN. 

observed,  as  already  stated.  Passing;  the  tincjer  above  the  nuu^s  in 
the  vagina,  in  search  of  the  walls  of  the  cervix  and  the  us  uteri,  a 
furrow  is  felt  which  shows  that  the  walls  of  the  vagina  and  uterus 
are  continuous,  and  that  there  is  no  opening  into  the  cavity  of  the 
uterus. 

These  signs  will  suffice  for  any  one  who  is  familiar  with  the 
normal  condition  of  the  parts  in  labor,  to  make  a  diagnosis.  In 
fact,  there  are  only  two  things  which  could  easily  be  mistaken  for 
inversion,  a  fibrous  tmnor  and  the  presenting  membranes  in  a  case 
of  twins.  The  latter  could  be  made  out  by  palpating  the  abdomen 
and  finding  the  large  uterus  with  the  child,  and  the  other,  though 
less  easily,  could  be  detected  by  the  presence  of  the  uterus  behind 
the  pubes  and  the  presence  of  the  uterine  canal  which  could  be  fol- 
lowed by  the  touch  beyond  the  tumor. 

These  physical  signs  should  be  sufficient  to  suggest  the  diagnosis, 
which  can  be  confirmed  by  restoring  the  inversion.  " 

This  is  easily  accomplished  by  any  one  familiar  with  obstetric 
manipulations.  When  there  is  complete  prolapsus,  as  well  as  inver- 
sion, the  diagnosis  can  be  made  by  inspection.  The  form  of  the 
tumor,  the  appearance  of  its  mucous  membrane,  the  presence  of  the 
placenta,  or,  in  case  that  it  has  been  detached,  the  irregular  appearance 
of  the  placental  site  compared  with  the  rest  of  the  membrane,  and 
the  contractions  of  the  uterus,  which  can  be  noticed  while  handling 
the  parts,  are  quite  sufficient  to  settle  the  diagnosis. 

In  old  cases,  in  which  the  uterus  has  become  reduced  to  its  origi- 
nal size  by  involution,  the  diagnosis  is  not  so  easy  as  in  recent  cases, 
and  yet,  by  the  aid  of  the  sound  and  the  bimanual  touch,  the  diag- 
nosis can  be  made  with  certainty  in  the  great  majority  of  cases. 

By  the  touch  the  round  tumor  is  found  projecting  into  the  va- 
gina, aud  the  lips  of  the  os  externum  can  be  distinguished  surround- 
ing the  tumor.  The  fornices  can  sometimes  be  made  out  also.  In 
most  of  the  cases  that  I  have  seen  the  cervix  was  thinned  out  so 
that  its  walls  felt  as  if  continuous  with  the  vagina,  and  the  fornices 
were  also  obliterated.  In  either  condition  the  evidence  is  in  favor 
of  inversion,  but  when  the  cervix  can  be  found  the  evidence  is  more 
valuable,  especially  if  the  finger  can  be  passed  up  into  the  cervix 
between  its  walls  and  the  body  of  the  uterus.  There  the  mucous 
membrane  of  the  cervix  can  be  felt  refiected  upon  the  tumor  to  the 
same  extent  all  around. 

These  signs  can  be  made  out  by  the  vaginal  touch.  The  biman- 
ual touch  is  still  more  satisfactory.  By  that  method  the  uterus  can 
be  raised  up  in  the  pelvis  by  the  finger  or  fingers  of  one  hand  in  the 


INVERSION   OF   THE   UTERUS. 


269 


vao"ina,  while  with  the  other  liand  a  body  with  a  depression  in  its 
center  can  be  felt  through  the  wall  oi  the  abdomen.  In  spare  pa- 
tients with  relaxed  abdominal  nmscles  the  bimanual  touch  will  usu- 
ally suffice  to  make  the  diagnosis  quite  positive. 

In  doubtful  cases  the  uterus  may  be  drawn  down  with  a  tenacu- 
lum or  pressed  dowm  by  a  hand  upon  the  abdomen,  while  a  rectal 
examination  with  the  index-finger  of  the  other  hand  is  made.  In 
this  way  the  fingers  of  the  two  hands  may  be  made 
to  meet  above  the  uterus,  and  at  the  same  time  the 
finger  in  the  rectum  may  detect  the  cup-shaj^ed  end 
of  the  uterus  above.  In  case  the  bimanual  touch 
is  not  practicable,  owing  to  the  patient  being  very 
stout,  or  the  abdominal  muscles  unyielding,  the  same 
signs  can  be  obtained  by  passing  a  sound  into  the 
bladder  and  turning  it  backward  until  it  meets  the 
finger  in  the  rectum  above  the  uterus. 

To  facilitate  either  or  both  of  these  methods  of 
examination  by  the  touch,  the  uterus  may  be  drawn 
downward  by  a  noose  made  of  tape  or  rubber  passed 
aronnd  the  cervix,  as  recommended  by  Barnes. 

Chronic  inversion  is  likely  to  be  mistaken  for 
fibrous  polypus  of  the  uterus.  A  number  of  mis- 
takes of  this  kind  are  on  record,  but  most  of  them 
occurred  before  the  time  when  the  uterine  sound 
and  the  bimanual  touch  were  employed  for  diag- 
nostic purposes.  The  differentiation  can  usually  be 
made  by  the  methods  of  examination  already  de- 
scribed. 

In  polypus,  the  uterine  sound  can  be  passed  be- 
yond the  tumor  into  the  uterus  above,  whereas,  in 
inversion,  the  progress  of  the  sound  is  arrested  at 
the  neck  of  the  uterus.  The  bimanual  touch,  rec- 
tal touch,  and  vesico-rectal  examination,  reveal  the 
uterus  above  the  tumor.  The  inverted  uterus  is 
tender,  the  polypus  is  not.  This  sign  is  of  much 
value.  By  seizing  the  tumor  and  turning  it  around 
it  will  move  in  the  cervix  if  it  is  a  polypus.  The 
Fig.  126— Polypus   i^^q  surfaces  will  glide  backward  and  forward  ui^on 

simulating     com-  i  t  i  .       . 

plete     inversion   each  other,  but  m  inversion  no  such  motion  can  be 
(Thomas).  produced.     Incomplete  inversion  is  not  easily  diag- 

nosticated under  the  most  favorable  circumstances.  To  distinguish 
partial  inversion  from  an  intra-uterine  fibroid  of  small  size  is  next  to 


Fig.  125. — Polj-pus 
simulating  partial 
inversion  (Thom- 
as). 


/::m^-., 


\ 


270  DISEASES   OF   WOMEN. 

impossible.  Fortunately,  sueli  a  diagnosis  is  not  imperative,  because 
active  treatment  is  not  often  called  for  in  these  incomplete  and 
doubtful  cases. 

Prognosis. — Inversion  is  always  a  grave  condition.  Tf  it  does 
not  prove  fatal  at  tirst  from  shock  and  luemorrhage,  it  becomes  a 
continuous  ti-ouble,  which  either  gradually  undermines  the  general 
health,  and  thereby  shortens  life,  or  else  keeps  the  subject  in  a  state 
of  impaired  usefulness  and  ill  health.  There  is  no  certain  tendency 
to  natural  recovery,  and  although  quite  a  number  of  cases  have  been 
recorded  in  which  spontaneous  rej>lacement  of  the  uterus  was  said  to 
have  taken  place,  such  an  occurrence  must  be  very  rare.  From  the 
fact  that  most  of  these  cases  are  recorded  by  the  older  authors,  it  is 
possible  that  in  some  of  them  the  diagnosis  was  incorrect.  One  thing 
is  certain,  no  such  fortunate  termination  should  be  expected  or  relied 
upon.     Without  treatment  the  condition  will  probably  continue. 

The  ])rognosis  is  rendered  more  grave  by  the  fact  that  the 
treatment  is  not  without  danger. 

There  are  several  methods  of  treating  inversion,  but  neither  of 
them  is  wholly  safe.  This  statement  applies  to  chronic  inversion. 
When  the  inversion  occurs  during  labor,  immediate  replacement  is 
easy  and  not  attended  with  any  great  risk.  The  dangers  in  restor- 
ing an  old  inversion  are  from  inflammation  and  septicaemia,  pro- 
duced by  the  injm'ies  to  the  uterus,  vagina,  and  adjoining  parts 
during  the  violent  efforts  necessary  to  accomplish  the  object.  These 
dangers  are  greatly  increased  by  unskillful  operating,  still  unfortunate 
results  have  occurred  in  the  practice  of  the  most  skillful  surgeons. 

Causation. — The  conditions  which  predispose  to  inversion  are 
enlargement  of  the  uterus  and  relaxation  of  its  tissues.  These  are 
best  illustrated  in  the  puerperal  state.  Inversion  can  not  take  place 
in  a  normal  non-puerperal  uterus.  The  condition  of  the  uterus  im- 
mediately after  the  delivery  of  the  child  is  most  favorable  to  the 
accident,  and  it  is  at  this  time  and  under  these  circumstances  that 
inversion  most  frequently  occurs. 

Predisposing  causes,  other  than  pregnancy  or  parturition,  are 
known,  but  they  are  operative  in  bringing  about  a  condition  of  en- 
largement of  the  uterus  and  relaxation  of  its  tissues.  These  are 
distention  of  the  uterus  from  tumors  or  fluids.  The  relaxation  of 
tissues  which  is  found  in  imperfect  involution  and  prolapsus  is  also 
given  as  a  predisposing  cause,  but  I  have  not  seen  the  record  of  any 
case  which  could  be  clearly  traced  to  this  cause. 

To  briefly  restate  this  matter,  the  tendencies  to  inversion  depend 
upon  enlargement,  distention,  and  relaxation.     The  exciting  causes 


INVERSION   OF   THE   UTERUS.  271 

are  traction  or  pressure  upon  the  fundus  uteri  when  it  is  in  a  con- 
dition favorable  to  inversion.  The  direct  causes  are  traction  upon 
the  umbilical  cord  or  pressure  upon  the  fundus  uteri  at  the  moment 
when  the  child  is  expelled,  or  sudden  delivery  of  the  child,  either 
by  traction  or  the  natural  muscular  efforts.  Muscular  eJfforts,  when 
there  is  relaxation  of  the  uterus,  are  meutioned  as  a  cause,  and  cases 
are  recorded  in  which  inversion  is  said  to  have  occurred  in  that  way, 
but  that  cause  must  be  seldom  operative.  Prolapsus  uteri  is  also 
credited  with  having  some  causative  relation  to  inversion,  but  I 
have  no  knowledge  on  this  subject.  Next  to  parturition  come  intra- 
uterine tumors  in  the  causation  of  inversion.  All  the  cases  which 
have  come  directly  under  my  own  observation,  or  that  have  come  to 
my  knowledge  indirectly  through  competent  contemporary  authori- 
ties, have  been  clearly  traceable  to  parturition  or  hbrous  polypi. 

The  conditions  are  alike  in  pregnancy  and  intra-uterine  tumors, 
so  far  as  the  uterus  is  concerned  in  the  predisposition  to  inversion. 
There  is  enlargement  of  the  uterus  with  relaxation  followed  by 
muscular  contraction.  During  the  growth  of  the  tumor  the  uterus 
increases  in  size,  and  finally  endeavors  to  expel  the  growth,  and 
when  the  muscular  contractions  are  going  on  the  fundus  uteri  is 
dragged  downward  by  the  pedicle  of  the  tumor.  In  this  way  all 
the  predisposing  and  mechanical  conditions  are  jjresent  which  are 
most  competent  to  cause  inversion. 

Treatment. — There  are  several  methods  of  managing  inversion. 
Of  course  the  indications  are  to  restore  the  uterus  to  its  proper  rela- 
tions. This  is  often  difficult  in  chronic  inversion,  and  sometimes 
impossible,  hence  other  means  must  be  employed  to  give  all  relief 
possible. 

In  case  replacement  can  not  be  accomplished,  the  most  promi- 
nent symptoms  should  be  relieved  by  treatment ;  haemorrhage  should 
be  controlled  by  astringents  and  inflammation  should  be  reduced  by 
appropriate  care.  Inversion  can  be  successfully  treated  if  seen  im- 
mediately after  it  occurs.  The  method  of  operating  is  to  grasp  the 
uterus  in  the  right  hand,  and  carry  it  upward  until  the  cervix  can 
be  felt  with  the  left  hand  through  the  abdominal  wall ;  counter- 
pressure  is  then  made  while  the  fundus  uteri  is  being  forced  upward 
with  the  right  hand  in  the  vagina.  The  abdominal  walls  being  thor- 
oughly relaxed,  as  they  are  immediately  after  confinement,  the  bi- 
manual manipulations  are  comparatively  easy.  The  os  uteri  can  be 
felt  with  the  left  hand,  and  by  pressing  the  abdominal  wall  down 
into  it  with  the  fingers  it  is  dilated,  and  when  the  fundus  is  restored 
far  enough  to  engage  in  the  os,  the  lips  of  the  cervix  can  be  pushed 


272  DISEASES    OF    WOMEN, 

over  the  fuiidus,  in  tljc  same  way  that  they  are  pushed  over  the  head 
of  the  child  in  dehverv. 

Cases  of  Recent  Inversion. — I  have  seen  four  cases  of  inversion 
soon  after  they  occurred,  one  in  my  own  practice  and  three  in  con- 
sultation. 

Two  of  these  were  inversion  with  complete  prolapsus,  and  the 
otlier  two  were  uncomi)licated.  My  own  ease  was  that  of  a  strong 
young  woman  in  her  second  confinement.  The  pelvic  outlet  was 
rather  narrow,  and  the  perinseuin  rigid,  so  that  the  pains  which  ex- 
pelled the  head  were  most  powerful,  especially  the  last  one.  The 
moment  that  the  head  passed  the  perinseum  the  whole  child  was 
expelled  with  extraordinary  force.  While  the  nurse  rested  her  hand 
upon  the  abdomen  I  tied  the  cord,  and  then  I  found  the  placenta 
presenting  at  the  vulva,  I  passed  my  linger  up  to  bring  the  edge 
down  and  then  deliver  it,  but  I  found  a  hai'd  body  above  to  which  it 
was  attached.  I  then  passed  my  left  hand  over  the  abdomen,  and 
found  that  the  uterus  was  not  there.  Inversion  was  suspected,  and 
I  at  once  sepai'ated  and  removed  the  placenta,  which  was  very  easily 
done  in  this  case,  and  then  witli  bimanual  manipulation  restored  the 
uterus  with  the  greatest  facility.  The  removal  of  the  placenta  and 
the  reduction  of  the  uterus  occupied  but  a  moment.  The  patient  did 
not  apparently  suffer,  but  I  think  that  there  was  slight  shock  and 
consequent  anaesthesia,  so  that  the  reduction  was  painless  and  finished 
before  she  reacted. 

I  found  I  could  grasp  the  fundus  easily,  and  by  making  firm  ]->ress- 
m'e  upon  one  comer  with  my  thumb  and  upon  the  other  with  the 
middle  finger,  and  thus  raising  the  whole  uterus  up  until  I  could  feel 
the  OS  with  the  fingers  of  the  left  hand,  the  pressure  and  counter- 
pressure  effected  the  reduction  with  ease  and  rapidity. 

I  found  that  the  reduction  of  one  horn  first,  as  recommended  by 
Dr.  Noeggerath,  answered  well,  first  because  the  horn  was  more 
easily  brought  under  pressure,  and  also  because  it  appeared  to  yield 
most  readily.  In  grasping  the  uterus  the  thumb  naturally  rests 
upon  one  horn,  and  by  making  firm  pressure  at  that  ]iart,  which  is 
more  convenient  than  to  press  upon  the  center  of  the  fundus,  it 
appears  to  be  the  natural  way  of  effecting  reduction  by  the  unaided 
hand.  The  hand  was  made  to  follow  up  the  reduction,  so  that  when 
it  was  completed  the  hand  was  fully  within  the  utenis,  and  it  was  left 
there,  and  pressure  upon  the  utenis  with  the  left  hand  upon  the 
abdomen  was  made  until  the  uterus  contracted  and  the  hand  was 
expelled.  This  was  the  part  of  the  procedure  which  required  the 
most  time,  owing  to  the  uterus  being  slow  to  contract. 


INVERSION   (;F  the   UTERUS.  273 

The  three  other  cases  were  seen  in  the  practice  of  others.  One 
that  I  saw  with  Dr.  A.  R.  Matheson,  was  a  complete  prolapsus  as 
well  as  inversion.  I  saw  the  patient  in  about  half  an  hour  after  the 
inversion  occurred.  There  was  considerable  shock,  and  the  doctor 
was  obliged  to  hold  the  uterus  with  the  placenta  attached  in  the  firm 
grasp  of  both  hands  to  prevent  haemorrhage.  The  prolapsus  was 
reduced  first  and  then  the  inversion,  in  the  same  way  and  in  about 
the  same  time  as  the  case  just  described.  I  saw  another  case  of  in- 
version and  prolapsus  with  Di-.  Bliss.  It  was  of  three  days'  stand- 
ing. The  doctor  did  not  attend  in  confinement,  but  was  called  to 
see  the  patient  because  of  the  inversion.  When  I  saw  her  she  was 
exceedingly  weak.  The  pulse  140,  and  feeble.  She  was  anasmic, 
and  the  abdomen  greatly  distended  and  tender  to  the  touch.  The 
uterus  was  resting  between  the  limbs,  and  parts  of  the  mucous  mem- 
brane here  and  there  were  in  a  sloughing  condition,  and  other  por- 
tions were  dry  and  glazed  looking.  Yasehne  was  applied  over  the 
whole  surface,  and  the  uterus  first  pushed  up  into  the  vagina  and 
then  grasped  with  the  hand,  and  the  inversion  reduced.  The  opera- 
tion in  this  case  was  more  difficult  and  prolonged.  Owing  to  the 
tympanitic  state  of  the  abdomen  it  was  difficult  to  make  proper 
pressure  upon  the  lips  of  the  cervix,  and  that  was  a  cause  of  delay. 
The  extreme  depression  of  the  patient  (while  it  raised  a  doubt  as  to 
her  being  able  to  stand  the  operation  of  reduction)  gave  that  com- 
plete relaxation  and  general  anaesthesia  which  was  favorable.  No 
anaesthetic  was  given.  In  about  ten  minutes  the  reduction  was 
effected.     The  patient  recovered. 

One  other  case  I  saw  with  Dr.  Bodkin.  The  inversion  occurred 
at  two  o'clock,  and  three  hours  later  it  was  reduced.  There  was 
some  excitement  of  the  pulse,  and  the  patient  had  pelvic  pain. 
There  was  very  little  haemorrhage,  but  there  had  been  considerable 
at  the  confinement.  Chloroform  was  administered,  and  the  reduc- 
tion was  accomplished  by  the  same  method.  More  time  was  required 
than  in  either  of  the  other  cases,  because  there  was  more  contraction 
of  the  uterus,  but  by  means  of  upward  pressure  and  counter-pressure 
upon  the  lips  of  the  cervix  the  reduction  was  accomplished  in  a  short 
time. 

Chronic  inversion  is  far  more  difficult  to  manage  than  recent  in- 
version. In  fact,  when  the  inversion  has  existed  long  enough  to 
permit  the  uterus  to  regain  its  original  size,  or  nearly  so,  by  involu- 
tion, and  has  contracted  firmly,  its  reduction  is  always  difficult,  and 
sometimes  impossible.  This  has  led  surgeons  to  devise  several 
methods  of  reducing  this  inversion  under  these  circumstances. 
19 


274  DISEASES   OK   AVOMEX. 

Dr.  Thomas  has  elassiiied  tliese  methods  as  follows :  ^Methods 
of  effecting  gradual  reduction  and  methods  of  effecting  rapid  reduc- 
tion. The  method  of  reduction  by  taxis  is  the  oldest  and  most  re- 
liable, and  should  be  tried  first  in  all  cases,  because,  if  it  fails,  the 
gradual  reduction  may  be  tried  subsequently,  ])rovidiiig  that  the 
taxis  is  not  so  violent  and  prolonged  as  to  cause  fatal  inflammation. 

Tiiere  are  several  ways  of  applying  taxis,  but  only  two  ways  of 
attaining  the  desired  end.  The  pi'inci])le  of  tiie  one  is  to  reduce 
first  that  portion  which  was  last  inverted,  and  the  other  is  to  reduce 
the  fundus  first  and  dilate  the  cervix  at  the  same  time,  so  that  the 
portion  first  inverted  is  first  reduced.  To  some  extent  both  objects 
may  be  attained  at  the  same  time  by  so  manii)ulating  that  both 
changes  of  position  may  go  on  together.  The  method  of  oj)erating 
is  as  follows :  The  patient  should  be  placed  upon  the  operating 
table  in  the  dorsal  position,  and  the  surge'on's  liand  carefully  in- 
troduced into  the  vagina.  It  is  necessary  to  dilate  the  vagina,  in 
the  great  majority  of  cases,  in  order  to  admit  the  hand.  Some- 
times the  dilatation  is  difhcult  to  accomplish  with  the  hand  without 
mpturing  the  vagina.  When  this  is  the  case,  dilatation  as  a  pre- 
liminary measure  should  be  accomplished  by  stretching  witii  the 
speculum  and  the  inflatable  rubber  bag.  The  right  hand  is  introduced 
into  the  vagina  and  the  uteras  grasped  with  the  thumb  and  fingers. 
The  uterus  is  compressed  and  at  the  same  time  carried  u])ward,  and 
held  against  the  left  hand,  which  makes  the  counter-pressure.  The 
manipulations  with  the  right  hand  should  be  so  directed  that  one  or 
both  horns  should  be  reduced  first.  The  cervix  should  be  dilated, 
and  reduction  begun  at  that  point  at  the  same  time  that  reduction 
of  the  horn  is  effected.  Fortunately,  the  efforts  to  accomplish  the 
one  favor  the  other. 

This  method  of  Noeggerath's,  which  has  already  been  discussed, 
is  that  which  I  prefer,  but  there  are  certain  modifications  which  are 
of  value  in  certain  cases,  and  should  be  employed  when  failure  of 
the  one  method  makes  the  trial  of  the  modified  methods  necessary. 
For  example,  Dr.  Thomas  has  employed  a  cone  of  wood  in  place  of 
the  left  hand  for  dilating  the  cervix.  In  thin  patients  this  can  be 
inserted  into  the  ring  of  the  cervix,  which  can  be  felt  through  the 
abdominal  walls,  and  gradually  forced  into  the  cervix  until  sufficient 
dilatation  is  obtained.  Barren  placed  the  fingers  around  the  body  of 
the  uterus  and  the  thumb  upon  the  fundus,  and  forced  the  cervix 
against  the  sacrum  to  secure  counter-pressure. 

Courty's  method  consists  in  using  the  index  and  middle  fingers 
of  the  left  hand  in  the  rectum,  to  dilate  the  cervix  and  make  couu- 


INVERSION   OF  THE   UTERUS.  2Y5 

ter-pressure.  This  method  of  using  the  left  liand  combined  with 
the  method  of  Dr.  Noeggerath  is  higlily  commended  by  Dr.  T.  G. 
Thomas.  Dr.  Emmet  describes  his  method  as  follows  :  "  In  18C5  I 
succeeded  in  eifectiiig  a  reduction  by  passing  my  hand  into  the  va- 
gina, and,  with  the  fingers  and  thumb  encircling  the  })ortioii  of  the 
body  close  to  the  seat  of  inversion,  the  fundus  was  allowed  to  rest 
in  the  palm  of  the  hand.  This  portion  of  the  body  was  firmly 
grasped,  pu8hed  upward,  and  the  fingers  were  then  immediately 
separated  to  their  utmost ;  at  the  same  time  the  other  hand,  was  em- 
ployed over  the  abdomen  in  the  attempt  to  roll  out  the  part  form- 
ing the  ring,  by  sliding  the  abdominal  parietes  over  its  edge.  This 
raanoBUvre  was  repeated  and  .continued.  At  length,  as  the  trans- 
verse diameter  of  the  uterine  cervix  and  os  was  increased,  by  lateral 
dilatation  with  the  outspread  fingers,  the  long  diameter  of  the  body 
became  shortened,  and.  the  degree  of  inversion  proportionately  less- 
ened. After  the  body  had  advanced  w^ell  within  the  cervix,  steady 
upward  pressure  upon  the  fundus  was  applied  by  the  tips  of  all  the 
fingers  brought  together." 

This  method,  which  appears  to  me  like  Yandel's,  is  natural  in 
theory,  but  in  trying  it  I  have  found  that  I  could  not  separate  the 
fingers  to  any  extent,  owing  to  the  fact  that  the  extensor  muscles  are 
feeble  in  their  action,  and  not  capable  of  doing  more  than  resisting 
the  pressure  of  the  vagina. 

Dr.  Emmet  also  commends  the  closure  of  the  cervix  with  silver 
sutures  in  cases  where  the  reduction  can  not  be  completed.  He 
gives  a  diagram  representing  the  cervix  as  being  about  three  times 
as  long  as  the  body,  and  drawn  over  the  fundus  and  held  there  by 
sutures.  I  have  never  practiced  this  treatment  for  the  reason  that 
in  all  the  cases  in  which  I  have  been  able  to  get  the  body  and  fun- 
dus reduced  wholly  within  the  cervix,  the  complete  reduction  has 
been  easily  and  speedily  accomplished.  Again,  I  can  not  see  how 
sutures  of  any  kind  would  resist  the  pressure  of  a  partially  inverted 
uterus,  with  a  strong  tendency,  which  there  always  is,  to  become 
further  inverted. 

Repositors  have  been  used  to  aid  in  the  taxis  by  De  Paul,  Avel- 
ing.  White,  and  others.  The  most  useful  of  these,  and  one  that 
fulfills  the  requirements  is  that  invented  by  Dr.  John  Byrne,  of 
Brooklyn.  It  consists  of  a  cup  and  stem  with  a  movable  plug  or 
button  in  its  center.  The  button  forms  the  bottom  of  the  cup  when 
it  is  placed  over  the  uterus,  and  while  the  cup  is  in  place  the  plug 
is  pushed  forward  by  the  screw  in  the  handle  against  the  fundus, 
and  in  that  way  makes  the  required  upward  pressure. 


276 


DISEASES  OF   WOMEN. 


Fig.  127. — Byrne's  method  of  reduction. 


Fig.  127  shows  Dr. 
Byrne's  repositor  as  used, 
and  its  cup  or  bell-shaped 
instrument  with  the  plug 
and  screw  adjustment  for 
making  counter  -  pressure 
and  dilatation  of  the  cervix. 
A  piston  in  the  lower  cup 
pushes  the  fundus  up. 
There  are  a  numljer  of  ad- 
justable cups  which  can  be 
adapted  to  the  require- 
ments of  different  cases. 

Cases  are  sometimes  met 
M'hich  can  not  be  restored 
by  taxis.  Kesort  must  then 
be  had  to  such  means  as 
gradual  reduction  by  con- 
tinuous pressure.  Thiti  is 
effected  by  a  cup  and  stem 
(Fig.  128)  which  are  held  in  place  by  a  perineal  band  of  i-ubber  or 
elastic  fastened  to  a  bandage  applied  around  the  pc^lvis.  When  using 
this  instrument  care 
must  be  taken  to 
keep  the  uterus  in 
the  line  of  press- 
ure. When  the  va- 
gina is  relaxed  the 
uterus  may  fall 
backward  or  for- 
ward out  of  the 
line  of  pressure  ; 
this  can  be  avoided 
by  using  a  tampon 
around  the  uterus, 
which  may  be  worn 
for  two  days  if  no 
great  distress  is 
caused  by  it.  It 
should  be  examined 
from  time  to  time, 

and  if  there  is  much    Fig.  128. — Cup  pessary  to  exercise  gradual  pressure  (Thomas) 


INVERSION   OF  THE   UTERUS.  277 

irritation  the  instrument  should  be  removed  and  vaginal  injections 
used  until  relief  is  obtained,  and  the  use  of  the  instrument  may  be 
aeain  resumed. 

The  rubber  bag  tilled  with  water  answers  a  very  good  purpose. 
To  apply  this,  the  patient  should  be  placed  in  Sims's  position,  and 
through  the  speculum,  the  upper  portion  of  tlie  space  between  the 
uterus  and  vagina  should  be  tilled  with  prepared  wool ;  then  the  bag 
should  be  introduced  between  the  fundus  uteri  and  the  pelvic  floor, 
and  distended  with  water.  A  firm  perineal  band  is  then  used  to 
support  the  pelvic  tioor.  Dr.  Thomas  recommends  a  strip  of  adhe- 
sive plaster  for  the  perineal  band,  one  end  being  fastened  to  the 
sacrum  and  the  other  to  the  abdomen,  with  two  ojDenings,  one  for 
the  tube  of  the  bag,  and  the  other  opposite  the  urethra  to  permit 
urination.  I  prefer  the  ordinary  muslin  or  elastic  band,  because  it 
is  more  easily  removed  and  readjusted.  The  degree  of  pressure  and 
the  time  which  it  should  be  continued  must  depend  upon  the  re- 
sults. 

If  there  is  much  pain  or  irritation  the  treatment  must  be  sus- 
pended. The  combination  of  elastic  pressure  and  taxis  has  been 
employed  with  advantage.  After  the  pressure  has  been  used  for  a 
time  taxis  should  be  tried,  and  in  case  this  fails  the  elastic  pressm'e 
should  be  again  attempted.  Care  must  be  exercised  in  the  use  of 
taxis — it  should  not  be  too  violent  or  long-continued ;  this  must  be  de- 
cided by  the  operator  in  each  case. 

Dr.  Charles  Martin,  of  France,  succeeded  by  using  a  stream  of 
cold  water  projected  against  the  fundus  uteri,  through  the  speculum. 
This  he  employed  twice  a  day.  The  stream  was  thrown  with  con- 
siderable force ;  he  also  filled  the  speculum  with  cold  water,  and 
kept  the  uterus  in  it  three  or  four  minutes.  Dr.  T.  G.  Thomas, 
from  whose  work  I  take  the  above  statement,  approves  of  this 
method. 

Dr.  Thomas  has  devised  another  method,  which  I  understand 
he  employs  or  advises  where  other  methods  fail.  The  following  is 
taken  from  his  work  on  diseases  of  women :  "  Thomas's  method 
consists  in  abdominal  section  over  the  cervical  ring,  dilatation  with 
a  steel  instrum.ent,  made  like  a  glove-stretcher,  and  reposition  of  the 
inverted  uterus  by  any  one  of  the  methods  mentioned,  by  the  hand 
in  the  vagina.     Fig.  129  will  render  this  clear. 

"  This  procedure,  let  it  be  remembered,  is  not  offered  as  a  method 
of  treating  inversion  of  the  uterus,  but  as  a  substitute  for  amputa- 
tion. Few  cases  will,  I  think,  resist  elastic  pressure  and  judicious 
taxis ;  but  that  some  will  do  so  can  not  be  questioned.     It  is  to 


278 


DISEASES   OF  ^'OMEN. 


save   these   few   cases   from    amputation  that  I  suggest  abdominal 
section. 

"  One  of  the  cases  operated  on  in  this  way  has  proved  fatal.  Let 
it  not  be  forgotten  that  a  certain  number  of  these  cases  treated  by 
elastic  pressure  and  by  taxis  likewise  do  so,  for,  as  in  my  second 
case,  these  operations  are  often  performed  upon  exsanguinated 
women  whose  blood  is  impoverished.  One  instance  of  death  after 
reduction  by  elastic  pressure  is  recorded  by  Dr.  Tait  in  the  eleventh 
volume  of  the  '  London  Obstetrical  Transactions,'  while  one  of  the 

earliest  cases  on  record 
reduced  by  taxis — that  of 
Dr.  White,  of  Buffalo, 
likewise  ended  fatally." 

One  other  method  is 
worthy  of  mention,  name- 
ly, that  of  Dr.  Brown,  of 
Baltimore.  He  makes  a 
free  incision  in  the  fun- 
dus uteri,  and  through  the 
opening  thus  made  he 
Gtretehes  the  cervix  and 
then  reduces  by  taxis.  In 
case  of  failure  of  all  ef- 
forts, hysterectomy  may 
be  performed.  This,  I 
consider  advisable,  if  the 
patient  is  near  to  or  past  the  menopause,  but  it  should  not  be  un- 
dertaken until  all  other  methods  have  failed. 

There  are  several  methods  of  amputating  the  inverted  uterus. 
Dr.  McClintock  applied  a  string  ligature  around  the  highest  portion 
which  strangulated  the  uterus,  and  in  two  or  three  days  when  de- 
composition of  the  tissues  began,  he  amputated.  Hegar  accom- 
plished the  same  object  by  passing  strong  sutures  through  the  cer- 
vix, and  after  drawing  them  tight  enough  to  close  the  vessels  and 
close  the  peritoneal  cavity,  the  body  was  amputated. 

It  will  suffice  to  simply  mention  amputation  without  giving  elab- 
orate details.  It  was  frequently  practiced  in  the  past,  but  is  sel- 
dom heard  of  now.  Other  methods  succeed,  and  with  the  method 
of  Thomas  in  reserve — in  case  pressure  and  taxis  fail — amputation 
will  seldom,  if  ever  be  called  for.  Cases  might  be  quoted  to  illus- 
trate the  treatment  of  chronic  inversion,  but  they  would  add  noth- 
ing of  value  to  the  methods  of  operating  given  above. 


Fig.  129. — ^Tieplacement  of  uterus  by  dilatation 
throuErh  abdomen. 


CHAPTER  XVIL 

.     DISLOCATIONS    OF    THE    UTEKUS. 

The  uterus  is  peculiarly  subject  to  physiological  changes  of 
position.  The  bladder  in  front  causes  the  uterus  to  move  forward 
and  backward  according  to  its  dilatations  and  contractions.  In  a 
similar  but  much  less  extensive  way,  distention  of  the  rectum  acts 
to  push  the  uterus  forward.  The  abdominal  pressure  from  above  is 
constantly  changing,  and  is,  therefore,  constantly  affecting  the  posi- 
tion of  the  uterus  less  or  more.  The  movements  of  the  uterus 
under  the  influence  of  the  ever  varying  degrees  of  abdominal  press- 
ure are  easily  observed  by  watching  the  anterior  vaginal  wall  and 
uterus  through  a  Sims's  speculum  in  the  living  subject.  There  is 
an  up  and  down  motion,  very  limited  but  constant,  caused  by  ordi- 
nary respiration,  and  under  extra  exertion,  such  as  coughing,  the 
displacement  becomes  very  marked. 

Below  there  is  the  pelvic  floor,  which  has  least  of  all  to  do  with 
changing  the  position  of  the  uterus,  and  yet  much  to  do  in  counter- 
acting the  inclinations  to  displacement  produced  by  other  influ- 
ences. 

These  changes  of  position,  when  limited  in  degree,  are  physio- 
logical, the  organ  promptl}^  returning  to  its  original  position  as  soon 
as  the  displacing  influence  is  removed.  It  is  only  when  the  uterus 
remains  displaced  permanently  or  is  carried  far  beyond  the  physio- 
logical limits  that  the  dislocation  is  to  be  regarded  as  pathological. 
When  this  occurs,  the  malposition  gives  rise  to  suffering  from  de- 
ranged menstruation,  circulation,  and  innervation,  and  in  some  cases 
to  sterility.  Usually,  the  functions  of  the  bladder  and  rectum  are 
disturbed  and  the  general  system  suffers  from  reflex  influences.  It 
is  only  when  such  symptoms  as  these  are  present  that  displacements 
of  the  uterus  claim  the  attention  of  the  gynecologist. 

In  order  to  fully  comprehend  displacements  of  the  uterus  it  is 
very  necessary  that  the  normal  position  of  the  uterus  should  be 


280 


DISEASES   UF    WUMEN. 


flearly  understood,  and  this  can  only  he  attained  by  a  knowledge  of 
the  aiKitoniy  of  the  pelvic  organs. 

Anatomy. — In  discussing  this  subject  attention  will  be  chiefly 
(lirecteil  to  the  jiosition  of  the  uterus  in  the  pelvis,  its  relations  to 
neighboring  organs,  and  the  position  and  character  of  the  structures 
which  keep  it  in  position. 

One  would  naturally  turn  to  the  cadaver  in  the  hope  that  by 
careful  dissection  the  exact  position  of  the  uterus  could  be  deter- 
mined, but  after  life  is  extinct  the 
uterine  supports  hjse  their  tirra- 
ness,  and  changes  of  position  usu- 
ady  take  place.  Moreover,  it  fre- 
quently happens  that  the  pelvic  or- 
gans are  less  or  more  dis])laced 
toward  the  end  of  life,  so  that  a 
normal  state  of  the  parts  is  not 
often  found  in  the  cadaver.  Dis- 
section also  tends  to  displacement, 
no  matter  how  carefully  it  may  be 
performed.  To  obviate  this,  sec- 
tions of  the  frozen  subject  have 
been  made,  and  much  valuable  in- 
formation obtained  from  them. 
Still,  the  greater  part  of  useful  in- 
formation on  this  subject  must  be 
obtained  from  careful  and  oft-repeated  examinations  of  the  living 
subject.  With  information  obtained  from  all  these  sources  there  are 
still  differences  of  opinion  among  authors  on  certain  points. 

Under  the  circumstances,  in  place  of  giving  a  number  of  conflict- 
ing opinions,  it  will  be  better  to  give  the  views  which  I  have 
adopted  as  the  result  of  my  own  observations  on  the  living  subject, 
and  after  a  careful  investigation  of  the  views  of  others. 

In  the  first  place,  it  may  be  said  that  the  uterus  is  wholly  within 
the  true  pelvis. 

The  line  on  the  diagram  running  between  the  symphysis  pubis 
and  the  promontory  of  the  sacrum  divides  the  true  pelvis  from  the 
abdomen,  and  all  the  pelvic  organs,  the  uterus  included,  are  below  this 
plane,  the  superior  strait,  as  the  obstetricians  call  it  (Fig.  64).  The 
long  diameter  of  the  uterus  in  the  pelvis  corresponds  very  nearly  to 
the  axis  of  this  plane,  as  represented  by  the  line  (Fig.  13(»),  and  it  is 
equidistant  from  the  sides  of  the  pelvis. 

The  position  of  the  uterus  vai'ies  from  time  to  time,  as  already 


Fig.  130. — Section  of  pelvis,  showing  its 
inclination  and  the  axis  of  the  inlet. 


DISLOCATIONS   OF   THE   UTERUS. 


281 


stated,  but  in  all  its  changes  it  returns  to  the  axis  of  the  inlet  of  the 
pelvis,  slightly  behind  the  center  of  the  true  conjugate.  This  is  not 
iiiathematicallv  correct,  but  is  sufficiently  so  to  foi-m  a  basis  from 
which  further  studies,  both  anatomical  and  clinical,  may  be  con- 
ducted. 

In  order  to  obtain  some  idea  of  the  position  of  the  uterus  and  the 
influences  which  the  other  pelvic  organs  have  in  changing  this  posi- 
tion, reference  should  be  made  to  Fig.  64,  which  shows  a  section  of 
the  normal  pelvis.     Fig.  131  shows  the  changes  in  the  position  of 


Fig.   131. — The  normal  range  of  the  uterine  axis,  varying  according  to  the  distention  of 
the  bladder;  a,  with  bladder  empty  ;  d,  with  bladder  full  (Van  der  Warker). 

the  nterus  during  the  several  degrees  of  distention  of  the  bladder. 
These  physiological  changes  should  be  noted  and  the  causes  which 
give  rise  to  them,  in  order  that  they  may  be  recognized  clinically. 
Next  in  the  order  of  inquiry  are  the  anatomical  structures  by  which 
the  uterus  is  held  in  position.     This  requires  a  consideration  of  the 


282  DISEASES   OF    WUME.V. 

struetui-al  a.sPo('i;itioiis  of  tlie  uteriiH  and  all  the  other  pelvic  ortfans 
and  tissues.  The  position  of  the  several  pelvic  organs  may  he 
given  in  a  general  way  as  follows :  The  uterus  in  the  center,  Fallo- 
pian tuhes  and  ovaries  on  either  side,  the  bladder  in  front,  rectum 
behind,  and  the  vagina  below.  Covering  all  of  these,  except  the 
vagina,  is  the  peritonaium,  which  is  the  chief  bond  of  nnit)n  be- 
tween the  upper  jxtrtions  of  the  pelvic  organs,  and  ont  of  which 
are  formed  the  ligaments  which  have  much  to  do  in  keeping  the 
nterus  in  place.  The  peritonaeum,  while  it  covei-s  the  pelvic  organs, 
is  attached  to  the  bony  walls  of  the  pelvis  through  the  medium 
of  the  periosteum  and  areolar  tissue,  so  that  one  end  of  each  liga- 
ment may  be  said  to  have  an  attachment  to  the  inner  side  of  the 
pelvic  bones.  The  round  ligaments  are  anatomically  an  excejition 
to  this  rule.  They  contain  nmscidar  tissue  in  considerable  quan- 
tity, and  are  really  outgrowths  from  the  uterus  in  the  form  of 
round  cords,  whicli  start  from  the  uterus  near  the  proximate  ends  of 
the  Fallopian  tubes,  and  sweeping  round  the  outside  of  the  pelvis, 
pass  out  through  the  inguinal  rings  into  the  labia  majora.  These 
ligaments,  as  well  as  all  the  others,  can  be  seen  by  looking  down 
upon  the  pelvic  organs  in  situ.  The  uterus  is  seen  in  the  middle  of 
the  pelvis,  and  extending  across  on  either  side  of  it  are  the  two 
broad  ligaments  made  up  of  the  two  folds  of  peritona?um,  which 

unite  after  covering  the  uterus, 
Running  backward  from  the  uterus 
to  the  sacrum  are  those  peritoneal 
folds  known  as  the  utero-sacral  liga- 
ments. Between  the  uterus  and  the 
bladder,  on  the  sides  of  the  latter,  the 
folds  of  peritonteum  form  the  utero- 
vesical  ligaments.  These  ligaments 
Fig.  132.— Diagram  of  the  uterine  liga-  are  SO  Called,  not  because  they  are 

ments  as  seen  on  lookinjr  into  the  brim.  j     x   t  j.   ,  „  j.'  \  ..*. 

°  composed  oi  hgamentous  tissue,  Imt 

rather  because  they  perform  a  function  similar  to  that  of  ligaments. 
With  the  exception  of  the  round  ligaments  which  are  composed  of 
muscular  tissue  covered  with  peritonaeum,  the  others  are  made  up 
of  double  folds  of  peritonaeum  containing  between  these  folds  are- 
olar tissue  and  some  fibers  of  the  pelvic  fiuscia. 

An  idea  of  the  position  of  these  ligaments  and  their  relations  to 
the  uterus  may  be  obtained  from  Fig.  132. 

I  have  noticed  that,  in  the  dissecting-room,  gentlemen  are  not 
able  at  all  times  to  find  the  utero-sacral  and  utero-vesical  ligaments ; 
the  broad  and  round  ligaments  they  easily  note.     The  others  can  be 


DISLOCATIONS  OF  THE   UTERUS.  283 

brought  into  view  in  the  following  manner  :  If  the  uterus  be  drawn 
well  forward  by  a  tenacuhini,  two  tense  bands  will  be  seen,  the  utero- 
sacral  ligaments,  extending  from  the  side  of  the  uterus  back  to  the 
sacrum,  and  as  they  are  thus  raised  up  a  pouch  of  peritonfeum  ap- 
pears between  them.  This  is  the  sac  of  Douglas.  By  reversing 
this  manipulation,  and  drawing  the  uterus  backward,  the  utero- 
vesical  ligaments  will  be  seen  running  forward  on  either  side  of  the 
bladder. 

The  utero-vesical  ligaments,  in  addition  to  their  attachments  to 
the  uterus  and  bony  walls  of  the  pelvis,  are  also  connected  indirect- 
ly to  the  anterior  vaginal  wall  by  intervening  areolar  tissue.  The 
utero-sacral  are  connected  in  the  same  indirect  way  with  the  upper 
portion  of  the  posterior  vaginal  wall,  and  also  to  the  rectum,  on  the 
left  side  at  least. 

At  the  junction  of  the  supra-vaginal  portion  of  the  cervix  and 
body  of  the  utenis  all  the  ligaments,  except  the  round  ones,  are 
attached.  Here  also  the  anterior  and  posterior  vaginal  wall  and  a 
portion  of  the  bladder  join  these  other  structures. 

The  union  of  these  structures  at  this  point  is  not  direct,  but  is 
through  the  intervention  of  areolar  tissue  which  is  found  in  con- 
siderable quantity  in  this  region.  From  this  it  will  be  seen  that 
these  ligaments  are  continuous  from  side  to  side,  and  also  from  be- 
fore backward. 

The  chief  function  of  these  ligaments,  aided  by  the  anterior 
vaginal  wall,  is  to  keep  the  uterus  and  bladder  in  position.  This 
is  clearly  evident  from  the  mechanical  principle  apparent  in  the 
anatomical  arrangement  of  the  parts  in  question,  and  from  the  fact 
that  the  uterus  remains  in  place  for  a  considerable  time  when  the 
pehnc  floor  is  defective,  and  the  abdominal  pressure  more  marked 
than  normal. 

In  short,  many  cases  have  been  seen  clinically  in  which  all  the 
other  means  that  could  possibly  contribute  to  supporting  the  uterus 
were  removed  by  disease  and  injuries,  and  yet  the  uterus  was  main- 
tained in  position  under  ordinary  circumstances.  The  most  rational 
idea  of  the  means  and  ways  by  which  the  uterus  is  maintained  in 
the  pelvis  I  obtained  from  the  following  statement  by  Dr.  Frank  P. 
Foster.  Speald«g  of  the  supports  of  the  uterus,  he  says :  "  Ordi- 
narily, they  consist  wholly  of  the  anterior  wall  of  the  vagina  in 
front,  and  the  utero-sacral  lio-aments  behind,  which  tosfether  con- 
stitute  Avhat  may  be  called  a  beam  traversing  the  pelvis  antero- 
posteriorly  on  which  the  uterus  rests,  being  interposed  between 
them,  firmly  attached  to  the  one  anteriorly  and  to  the  other  poste- 


284 


DISEASES   OF   \YOMEy. 


riorly,  making  them,  so  far  as  mei-haiiical  effect  is  coiicenied,  one 
structure."  This  is  a  cleai*  and  cumpreliensive  statement  of  the  prin- 
ciples upon  which  the  utero-sacral  ligaments  and  the  anterior  vagi- 
nal wall  act  in  supporting  the  uterus.  I  would  go  one  step  further 
than  Dr.  Foster,  however,  and  claim  a  like  function  for  the  other 
uterine  ligaments.    The  broad  ligaments,  firmly  attached  to  the  bony 

walls  of  the  pelvis,  and  holding 
the  uterus  in  their  folds,  make 
a  continuous  structure  extend- 
ing across  the  pelvis  in  its 
transverse  diameter. 

These  structures,  taken  to- 
gether, act  like  "  beams"  or  (to 
be  more  mechanically  accurate) 
cables  of  a  suspension-bridge, 
which  support  to  a  large  ex- 
tent the  uterus  in  its  center. 
The  utero  -  vesical  ligaments 
also  supplement  the  anterior 
vaginal  wall  as  a  supporting 
medium.  According  to  this 
view  of  the  subject,  the  chief 
supports  of  the  uterus  are  the 
anterior  vaginal  wall,  utero-sacral,  vesico-uterine,  and  broad  liga- 
ments. 

Fig.  133  shows  a  section  of  the  pelvis  with  these  ligaments  and 
the  anterior  vaginal  wall  with  the  uterus  resting  upon  them. 

Fig.  13-i  shows  a  transverse 
section  of  the  pelvis  just  in 
front  of  the  uterus  and  broad 
ligaments,  and  represents  these 
structures  and  the  manner  in 
which  they  support  the  uterus. 
A  similar  function  may  be 
claimed  for  the  round  liga- 
ments, at  least  so  far  as  their 
effect  in  preventing  the  back- 
ward displacement  of  the  uter- 
us. Some  have  claimed  that 
the  round  ligaments  have  but 

little  supporting  power  to  sustain  the  uterus  in  place,  while  oth- 
ers give  it  tinich  credit  in  this  direction.     Those  who  believe  in 


Fig.  133. — Section  of  pelvis  ^th  the  slings  of 
the  uterus ;  behind,  the  utero-sacral  liga- 
ments ;  in  front,  the  anterior  vaginal  wall 
(after  a  section  by  Hart). 


Fig.  134. — Diagram  of  the  uterus  slung  between 
the  broad  lijiaments. 


DISLOCATIONS   OF   THE   UTERUS. 


285 


Alexander's  operation  of  shortening  the  round  ligaments  for  the 
relief  of  retroversion  of  tlie  nterns  certainly  claim  great  8ui)porting 
power  for  these  ligaments,  and  with  good  reason,  I  think. 

Finally,  I  may  add,  that  I  believe  that  the  ligaments,  the  vagina, 
and  the  other  pelvic  organs  all  aid  in  keeping  the  uterus  in  position, 
and  are  sufficient  to  do  so  under  ordinary  circumstances.  Still,  when 
extraordinary  sti-ain  is  brought  to  bear  upon  the  pelvic  organs,  the 
pelvic  floor  supplements  these  supporting  structures.  Moreover,  the 
relation  of  the  trunk  to  the  pelvis  has  much  to  do,  if  not  in  keeping 
the  pelvic  organs  in  place,  certainly  in  freeing  them  from  pressure 
from  above. 

The  pelvis  is  so  placed  that,  in  the  erect  posture,  its  cavity  is  be- 
hind rather  than  beneath  the  abdomen,  and  the  abdominal  muscles 
partially  divide  the  greater  cavity 
from  the  lesser.  This  is  shown  in 
the  accompanying  diagram,  where 
the  arrow  indicates  the  direction  of 
the  force  transmitted  to  the  pelvis 
through  pressure  from  above  (Fig. 
135)." 

There  is  very  little  direct  ab- 
dominal pressure  upon  the  pelvic 
organs  in  the  erect  posture.  The 
axis  of  the  pelvis  is  backward  and 
downward,  while  that  of  the  ab- 
domen is  perpendicular,  so  that  the 
pressure  is  indirect  from  above. 

Some  claim  that  a  suction  power 
is  exerted  upon  the  pelvic  contents 
by  the  diaphragm.  It  is  said  to 
act  like  a  piston  in  the  cylinder  of 
a  pump.  There  is  reason  to  be- 
lieve there  is  something  in  this, 
from  the  fact  that,  on  examination 

through  a  Sims's  sp)eculum,  the  uterus  is  seen  to  rise  and  fall  wdth 
respiration.  This  motion  is  to  a  large  extent  arrested  when  the  pa- 
tient is  in  the  erect  posture. 

If  it  is  a  fact,  as  it  appears  to  be,  that  the  abdominal  organs  are 
fixed  by  suspension  in  their  normal  position,  and  that  in  their  descent 
during  this  limited  motion  the  pressure  upon  the  pelvic  organs  is 
indirect,  then  this  relationship  contributes  to  maintain  the  position 
of  the  pelvic  organs  as  surely  as  if  there  were  some  traction  or  suc- 


FiG.  135 


The  normal  inclination  of  the 
pelvis  and  the  transmission  of  force 
from  above. 


286  DISEASES  OF   WOMEN. 

tion   action  of  the   diaplira<j^iii  tending  to   draw   these    organs   up- 
ward. 

In  regard  to  tlie  pelvic  floor  and  its  rehitions  to  the  displacements 
of  the  uterus,  that  subject  has  been  fully  discussed  under  the  head 
(»f  injuries  of  the  pelvic  floor.  It  is  only  necessary  to  repeat  my 
belief  already  expressed  to  tiie  effect  that,  while  the  pelvic  floor  does 
not  directly  sui)port  the  uterus,  it  indirectly  aids  in  doing  so,  and  if 
it  is  lost  from  injury  prolapsus  of  the  pelvic  organs  follows  as  a  nile. 


DISPLACEMENTS    OF    THE    UTERUS. 

There  are  a  great  many  forms  of  displacement  of  tlie  uterus,  if 
every  change  of  position  of  that  organ  be  taken  into  account,  Ijut  of 
tliose  that  occur  as  primary  affections  there  are  only  two  that  are 
often  seen,  and  one  that  is  very  rare.  These  are  downward,  back- 
ward, and  forward — that  is,  prolapsus,  retroversion,  and  antever- 
sion. 

Prolapsus  and  retroversion  are  really  the  only  forms  of  displace- 
n:;ent  which  practically  claim  attention  in  this  connection.  These 
the  gynecologist  is  called  upon  to  treat  dailj'  as  primary  jiffections. 
Occasionally,  a  case  of  anteversion  may  be  seen  which  apparentl}''  is 
not  caused  by  some  other  affection  more  important  than  the  conse- 
quent displacement,  but  this  is  exceedingly  rare.  Again  the  uterus 
may  be  anteverted  to  a  considerable  extent  without  causing  the 
slightest  trouble.  This  form  of  displacement  (quite  a  rare  one)  is 
generally  produced  as  a  consequence  of  some  other  disease,  either  of 
the  uterus  itself  or  the  organs  and  tissues  around  it,  or  else  when  it 
does  occur  it  gives  no  trouble  ;  and,  as  a  rule,  very  little  can  be  done 
to  relieve  it  by  the  ordinary  methods  of  treating  uncom2)licated  dis- 
placements. Taking  all  this  into  account,  it  is  evident  that  the 
downward  and  backward  displacements  alone  demand  special  atten- 
tion, either  in  practice  or  in  the  discussion  of  the  subject. 

The  other  forms  of  displacement  of  the  uterus,  described  in  text- 
books, are  the  right  and  left  lateral  anteversions  and  retroversions. 
These  displacements  are  always  due  either  to  some  lesion  of  develop- 
ment or  to  some  previous  affection,  the  products  of  which  either 
push  or  pull  the  uterus  out  of  place.  There  is  also  a  retrocession 
of  the  uterus  and  an  antecession,  which  are  not  described  in  l)ooks. 
Perhaps  better  names  for  these  would  be  transposition  backward  or 
forward.  In  these  dislocations  the  uterus  is  found  either  behind  or 
in  front  of  the  axis  of  the  pelvic  cavity,  or  superior  strait.  These, 
like  the  lateral  dislocations,  are  secondary  to  some  abnormal  state 


DISLOCATIONS   OF   THE   UTERUS. 


287 


which  caused  them,  and  hence  tliey  are  to  be  loolvcd  upon  as  signs 
and  consequences  of  the  primary  disease. 

By  adopting  this  classification  it  simplifies  the  subject  vei-y 
much,  and  leaves  one  free  to  give  attention  to  the  downward  and 
backward  dislocations  and  their  pathology,  diagnosis,  causation,  and 
treatment.  Again,  the  two  forms  of  displacement  in  question  are 
the  only  conditions  of  malposition  that  can  be  directly  treated  with 
favorable  i-esults.  In  the  other  forms,  such  as  lateral  versions,  treat- 
ment must  be  employed  to  remove  the  morbid  states  which  push  or 
pull  the  uterus  out  of  place,  and  therefore,  the  discussion  of  such 
displacements  should  be  confined  to  the  diseases  which  cause  them. 


PROLAPSUS    OF    THE    UTERUS. 

This  is  a  downward  displacement  of  the  uterus  commonly  called 
falling.  It  is  of  necessity  always  associated  with  displacement  of  the 
other  pielvic  organs  and 
tissues,  to  a  greater  or  less 
extent,  according  to  the 
degree  of  descent  of  the 
uterus. 

There  are  several  de- 
grees of  prolapsus  uteri 
which  have  been  various- 
ly described.  While  au- 
thors designate  the  most 
important  stages  of  de- 
scent by  degrees,  it  should 
be  understood  that  practi- 
cally there  is  no  line  of 
demarkation  between  the 
degrees.  According  to 
this  arrangement,  when 
the  uterus  sinks  so  that 
the  cervix  rests  entirely 
on  the  pelvic  floor,  it  is 
named  prolapsus  of  the  first  degree  ;  when  the  uterine  axis  has  be- 
come vertical  or  coincides  with  the  axis  of  the  outlet,  the  cervix  ap- 
pearing at  the  vulva,  the  second  degree  is  present;  while  in  the 
third  degree  the  organ  is  partly  or  wholly  outside  the  introitus. 
Fig.  13G  shows  the  three  degrees,  and  may  convey  a  clearer  idea 
than  further  description. 


Fig.  136. — The  three  degrees  of  prolapsus.   The  upper 
outhne  is  a  little  above  the  normal  position. 


288  DISEASES  OF   WoME.V. 

By  pome  aiitliorities  all  the  doi^rces  of  prolapsus  in  wliicli  the 
uterus  still  ivniains  within  the  vulva  are  termed  incomplete,  while 
tliose  in  which  it  protrudes  partially  or  completely  beyond  the  vulva 
are  called  complete. 

This  latter  arrangement  of  the  subject  is  perhaps  as  easily  com- 
prehended and  as  useful  in  practice  as  any  other.  The  complete 
(logrci-  is  often  spoken  of  as  ])rocidentia. 

Pathology. — Prolapsus  of  the  uterus  takes  place  slowly,  as  a  ride. 
Sudden  prolapsus  may  possibly  occur,  but  it  must  be  a  rare  thinp,  ex- 
cept in  the  first  degree.  In  the  few  cases  that  I  have  had  an  oj)por- 
tunity  of  watching  from  beginning  to  completion,  the  disi)lacement 
has  been  gradual.  At  first  the  uterus  descended  to  the  first  degree 
of  prolapsus,  and  then  to  the  second,  and  finally  to  the  third  or  com- 
plete stage.  The  time  occupied  in  making  the  complete  descent 
varies  from  months  to  years.  The  changes  which  take  place  in  the 
supports  of  the  uterus  and  the  other  pelvic  organs  during  the  pro- 
gressive development  of  the  prolapsus  are  usually  the  same  in  all 
cases  with  few  exceptions,  but  the  order  in  which  they  appear  differs 
according  to  the  cause  of  the  descent.  This  again  depends  upon  the 
point  in  the  structures  at  which  the  lesions  begin  to  develop. 
There  are  three  methods  of  development  of  prolapsus.  In  the  first, 
the  uterus  begins  to  descend  because  it  is  too  heavy  and  makes  too 
great  demands  upon  its  immediate  supports,  or  else  these  supjiorts 
become  defective  from  pathological  changes.  This  is  a  descent  of 
the  utenis  from  loss  of  direct  support.  The  second  order  of  descent 
is  by  loss  of  the  pelvic  floor,  which  permits  the  vagina,  bladder,  and 
part  of  the  rectum  to  descend,  and  then  the  uterus  follows.  The 
third  in  order  is  made  up  of  the  two  others,  the  first  and  the  second, 
all  the  conditions  mentioned  in  those  being  operative  at  the  same 
time. 

The  changes  in  the  supports  are  elongation  from  imperfect  in- 
volution after  parturition,  or  stretching  produced  by  enlargement  of 
the  uterus,  or  pressure  on  it  from  above  by  long  standing,  stoo])ing, 
or  lifting.  In  the  former  condition  the  supports  are  too  long ;  in 
the  latter  they  are  attenuated  as  well  as  elongated.  In  both  states 
the  upper  portion  of  the  vagina  is  distended  and  the  bladder  slightly 
prolapsed  or  drawn  backward.  There  is  also,  in  some  cases,  loss  of 
the  areolar  tissue,  and  the  pelvic  fascia  has  lost  its  strength  of  fiber. 
This  traction  upon  the  rectum,  bladder,  and  the  blood-vessels  is  pre- 
sumed to  interru]>t  the  return  circulation.  Whether  that  is  a  fact  as 
regards  the  causation  or  not,  there  is  usually  a  passive  hyperemia 
of  the  parts  in  these  displacements.     These  changes  of  the  position 


DISLOCATIONS  OF  THE   UTERUS.  289 

and  relations  of  these  parts  are  gradually  developed.  In  case  the 
prolapsus  proceeds  to  the  third  degree,  the  pelvic  floor  gives  way 
under  the  influence  of  the  conthiued  pressure.  The  perineal  mus- 
cles become  overdistended  and  the  vulva  enlarged,  until  the  uterus 
is  permitted  to  protrude  without  resistance. 

In  the  second  order  of  the  development  of  prolapsus — that  is, 
where  the  loss  of  the  pelvic  floor  is  the  starting-point  of  the  mal- 
position, the  flrst  lesions  appear  in  the  vagina.  The  walls  of  the 
vagina  at  the  introitus  begin  to  protrude  and  their  descent  is  gener- 
ally attended  with  increase  of  tissue.  Usually  both  walls  prolapse 
together,  but  in  many  cases  one  or  the  other  takes  precedence.  As 
the  prolapsus  progresses  the  bladder  and  anterior  wall  of  the  rectum 
descend,  producing  rectocele  and  cystocele.  In  due  time  the  uterus 
follows  with  all  the  changes  in  its  supports  already  described  above. 
There  are  cases  in  which  the  prolapsus  begins  at  the  lower  part  of 
the  vagina,  while  there  is  no  apparent  injury  of  the  pelvic  floor. 
This  has  been  accounted  for  by  imperfect  involution  of  the  vagina 
after  child-bearing.  The  large,  heavy,  and  lax  walls  of  the  vagina 
make  undue  pressure  upon  the  pelvic  floor  and  it  gives  way  before 
them.  A  similar  state  of  things  occurs,  so  far  as  appearances  are 
concerned,  where  there  has  been  subcutaneous  laceration  of  the  mus- 
cles of  the  pelvic  floor  which  impairs  its  function. 

Prolapsus  of  long  standing  changes  the  structure  of  all  the 
tissues.  Atrophy  of  the  muscular  tissue  of  the  vagina  and  pelvic 
floor  occurs,  and  the  ligaments  of  the  uterus  lose  their  character- 
istics so  that  they  can  not  be  restored  to  their  original  state  by  any 
means. 

There  is  a  prolapsus  which  occurs  as  the  result  of  degeneration 
of  the  supports  of  the  uterus.  It  occurs  in  feeble  old  women  in 
whom  general  nutrition  is  greatly  impaired.  The  perinseum  and 
vagina  lose  their  elasticity,  the  adipose  and  areolar  tissue  disappear, 
and  the  vaginal  walls,  bladder,  and  atrophied  uterus  descend.  Such 
patients  are  also  subject  to  prolapsus  of  the  rectum  and  sometimes 
prolapsus  of  the  mucous  membrane  of  the  urethra.  I  have  called 
this  senile  prolapsus  to  distinguish  it  from  the  ordinary  descent  of 
the  uterus  which  usually  occurs  in  middle  life.  I  believe  it  to  be 
due  to  the  general  atrophy  of  the  pelvic  viscera  because  of  the  time 
of  life  when  it  occurs,  and  the  fact  that  I  have  seen  it  in  those  who 
have  not  borne  children.  The  first  case  that  I  carefully  studied  was 
in  an  old  maiden  of  seventy  years  of  age. 

Symptomatology. — The  natural  history  of  prolapsus  uteri  as 
manifested  by  symptoms  and  physical  signs,  difliers  to  some  extent 
20 


290  DISEASES   OF   WOMEN. 

ill  different  cases,  thoii<ijli  tlie  patlioloirjcal  conditions  appear  to  be 
the  same  in  all.  The  sutiering  caused  varies  accordin«i;  to  the  general 
health  and  nervous  sensitiveness  of  the  subjects  affected.  What  is 
more  strange  still,  is  the  fact  that  incomplete  prolapsus  often  causes 
more  suffering  than  the  more  advanced  stages.  It  is  not  an  uncom- 
mon thing  to  see  a  patient  with  complete  prolapsus  of  the  uterus 
who  complains  less  than  another  in  whom  the  uterus  is  still  within 
the  pelvis. 

The  sj'mptoms  indicative  of  prolapsus  uteri  maybe  classed  under 
two  heads  :  First,  the  derangement  of  the  fuiictions  of  the  other 
pelvic  organs,  and,  second,  the  disordered  nutrition  of  the  tissues  of 
the  pelvic  viscera  generally.  The  dragging  of  the  uterus  upon  the 
bladder  and  rectum,  and  the  almormal  pressure  cause  irritation, 
which  gives  rise  to  rectal  and  vesical  tenesmus.  The  constant  desire 
to  evacuate  the  rectum  and  bladder,  is  often  very  distressing.  These 
symptoms  are  greatly  aggravated  by  walking,  lifting,  coughing,  and 
especially  by  standing,  and  they  are  all  relieved  in  a  very  marked 
degree,  often  completely  so,  by  lying  down.  This  difference  in 
the  feelings  of  the  patient,  when  in  the  erect  or  recumbent  ])osi- 
tion,  is  a  diagnostic  point  of  veiy  great  value.  The  recumbent  po- 
sition generally  gives  relief  in  the  majority  of  the  diseases  of  the 
pelvic  organs,  but  not  so  markedly  as  in  displacements  of  the  uterus. 

The  malnutrition  produced  by  iriitation  and  deranged  circula- 
tion leads  in  time  to  inflammatory  affections  of  the  uterus  and  other 
pelvic  organs.  This  is  not  an  acute  inflammation  which  can  be  seen, 
but  a  hypersemia  accompanied  by  tissue  changes  such  as  areolar  hy- 
perplasia and  catarrhal  states  of  the  mucous  membrane.  It  is  prob- 
able that  the  endometritis  so  common  in  prolapsus  uteri  may,  in 
many  cases,  precede  the  displacement,  but  the  displacement  certainly 
tends  to  keep  it  up.  The  symptoms  of  these  affections  need  not  be 
given  here. 

The  symptoms  manifested  by  the  general  system  in  this  affec- 
tion are  not  marked  nor  special.  Beyond  the  backache  and  deranged 
digestion  which  often  accompany  prolapsus,  and  the  depression  which 
comes  from  a  consciousness  of  having  some  chronic  ailment  which 
impairs  locomotion  and  general  usefulness,  there  is  not  much  that 
need  be  mentioned. 

Physical  Sifjns. — In  prolapsus  in  the  first  degree,  the  uterus 
presses  the  posterior  vaginal  wall  downward,  and  encroaches  upon 
the  rectum  to  some  extent,  at  the  same  time  it  inclines  backward. 
In  some  cases  the  cervix  rests  so  heavily  upon  the  floor  of  the  pelvis 
that  it  becomes  flattened.     This  is  easily  detected  by  digital  exam- 


DISLOCATIONS  OF  THE  UTERUS. 


291 


ination,  which  reveals  the  descent  of  the  uterus.  The  space  from 
the  pubes  to  the  anterior  wall  of  the  body  and  fundus  uteri  is  en- 
larged and  remains  so  when  the  bladder  is  empty.  The  upper  por- 
tion of  the  vagina  is  often  relaxed  and  wider  than  normal. 


urethra 


anus 

posterior 

vagina' 

Vail 


anterior 
vaginal 


cervix 
Fig.  137. — ^Prolapsus  uteri  with  cystocele. 

In  the  second  degree  of  prolapsus,  the  os  points  toward  the  os- 
tium vaginae,  and  is  at  or  near  the  vaginal  outlet.  The  fundus  uteri 
lies  back  toward  the  sacrum  but  not  usually  so  far  as  in  marked  re- 
troversion. In  complete  prolapsus  the  uterus  protrudes  from  tlie 
vagina,  and  can  be  easily  recognized  by  inspection.  In  this  third 
degree  of  prolapsus,  the  bladder  and  anterior  wall  of  the  rectum 
are  usually  drawn  with  the  uterus,  and  in  extreme  cases,  the  urethra 
also.  The  extent  to  which  these  organs  accompany  the  uterus  in  its 
descent  varies  considerably.  This  may  be  determined  by  passing  a 
sound  into  the  bladder  and  ascertaining  its  direction,  and  the  same 
means  will  show  the  extent  of  the  prolapsus  of  the  rectal  walls. 


292 


DISEASES   OF   WOMEN. 


Dia(jno!<ift, — The  affections  which  Bimulate  prolapsus  uteri  are 
hy])ertrophic  elon;^ation  of  the  cervix,  tibrous  polypus,  and  iu ver- 
sion. A  polypus  and  an  inverted  uterus  may  be  excluded  by  the 
absence  of  the  os  and  cervical  canal,  and  by  the  fact  that  they  are 
covered  with  the  mucous  membrane  of  the  uterus,  while  the  pro- 
lapsed uterus  is  covered  with  the  mucous  membrane  of  the  vagina. 

The  elongation  of  the  neck  of  the  uterus  can  be  detected  by 
passing  the  sound,  and  at  the  same  time  pushing  the  utems  u})  into 
the  pelvis,  until  the  fundus  can  be  detected  by  palpation  of  the  ab- 
domen ;  that  is,  l)y  making  the  bimanual  examination.  The  fact 
that  this  hypertrophy  of  the  cervix  occurs,  as  a  rule,  in  those  who 
have  not  borne  children,  will  also  aid  in  the  diagnosis.  There  are 
cases  of  jjrolapsus  in  which  the  uterus  is  greatly  relaxed,  and  be- 
comes elongated,  so  that  the  sound,  when  passed  to  the  fundus, 
shows  a  great  increase  in  its  long  diameter.  By  replacing  the  uterus 
it  becomes  shortened  very  considerably ;  the  shortening,  I  presume, 
is  due  to  contraction  or  condensation  of  the  tissues.  This  has  been 
described  by  Emmet  as  a  process  of  telescoping,  l)ut  I  think  the 

term  is  ill  chosen.  One  can  not 
conceive  of  portions  of  the 
uterus  being  pushed  into  each 
other  like  sections  of  a  tele- 
scope. 

In  the  physical  examination 
of  prolapsus,  care  should  be 
taken  to  discover  any  compli- 
cations which  may  exist,  such 
as  neoplasms  of  the  uterus, 
which  greatly  increase  its  size, 
abdominal  tumoi's  which  crowd 
the  uterus  downward,  and  atro- 
phy of  the  muscles  of  the  pel- 
vic floor  and  vagina. 

Causation. — The  fine  ad- 
justment of  the  uterus  and  the 
means  which  keep  that  organ  in 
its  place,  and  yet  permit  con- 
siderable motion,  are  such  that 
any  increase  of  weight  of  the 
one,  or  loss  of  strength  of  the 
other  will  cause  displacement.  The  formation  of  the  pelvis,  and  its 
position  in  relation  to  the  vertebral  column :  the  character  of  the 


Fig.  138. — The  shallow  pelvis  with  lessened 
inclination  of  brim.  The  direct  action  of 
the  pressure  from  above  is  shown  by  the 
arrows. 


DISLOCATIONS  OF  THE   UTERUS. 


293 


Fig.  139. — Increased  inclination  of  in- 
let.   Pelvic  organs  escape  pressure. 


fiber  of  the  uterine  supports,  the  quantity  and  consistence  of  the 
areolar  and  adipose  tissue ;  one's  habits  in  regard  to  clothing,  posi- 
tion in  standing  and  sitting,  if  main- 
tained unduly  long,  character  of  oc- 
cupation, strength  or  weakness  of 
general  organization  ;  and  the  acci- 
dents and  injuries  incident  to  child- 
bearing,  all  have  certain  inHuences  in 
causing  dislocations  of  the  uterus. 

A  shallow  and  wide  pelvis  (Fig. 
138)  which  is  more  than  suthcient 
for  the  accommodation  of  its  con- 
tents, while  it  is  favorable  to  easy 
parturitions,  predisposes  to  descent 
of  the  uterus.  Again,  if  the  pelvis 
is  tilted  forward,  so  that  it  is  brought 
more  immediately  under  the  axis  of 
the  abdomen  (Fig.  138)  the  pelvic 
organs  are  constantly  under  greater 
pressure  than  normal,  and  prolapsus 
and  retroversion  are  likely  to  occur. 
These  facts  regarding  the  form  and 

position  of  the  pelvis  are  factors  of  great  importance  in  the  problem 
of  uterine  displacement,  and  deserve  more  attention  than  has  been 
given  to  them. 

The  habit  of  walking  erect  has  the  effect  of  maintaining  this 
favorable  relation  of  the  abdomen  and  pelvis,  while  stooping  disturbs 
this  harmony  of  relative  positions.  In  this,  both  in  regard  to  forma- 
tion and  habit  of  standing  and  walking,  there  is  the  greatest  diversity 
among  women.  The  tissues  of  the  uterine  supports,  when  defective 
in  quantity  or  quality,  are  incapable  of  performing  their  functions. 
These  effects  may  be  the  result  of  imperfect  development  such  as 
occurs  in  those  of  sedentary  habits  in  youth,  or  they  may  come  from 
debilitating  diseases.  In  the  one  case  they  have  never  been  well  de- 
veloped, and  in  the  other  they  have  become  atrophied.  Standing 
and  walking  to  an  extent  that  is  fatiguing,  bring  undue  strain  upon 
the  pelvic  organs,  and  if  persisted  in,  will  in  time  produce  prolapsus. 
Active  exercise,  with  liberal  periods  of  rest,  will  tend  to  strengthen 
the  uterine  supports,  but  fatigue  will  overcome  their  power  of  re- 
sistance. Stooping  forward  while  in  the  sitting  position  has  a  two- 
fold injurious  influence — it  interrupts  the  return-circulation  in  the 
pelvis  and  impairs  the  nutrition  of  the  organs  and  brings  increased 


294  DISEASES  OF  WOMEN. 

downward  pressure  to  bear  on  them.  The  position  of  the  girl  at 
the  sewing-machine  and  that  of  the  lady  of  leisure,  l)eiit  over  in  her 
easy-chair  while  reading  a  novel,  are  alike  hurtful,  but  W(»rst  of  all, 
the  sehool-girl,  bending  over  her  desk  all  day,  while  her  body  is,  or 
should  be  developing,  suffers  the  most  injury.  Among  the  errors 
in  the  use  of  clothing,  the  abuse  of  corsets  does  the  most  harm.  I 
would  not  be  understood  as  condemning  corsets.  Long  use  has  ren- 
dered that  kind  of  support  necessary  to  highly  civilized  women,  but 
tight-lacing  forces  the  abdominal  viscera  out  of  place  and  in  tiuie 
displaces  the  pelvic  organs. 

Heavy  lifting,  if  persisted  in,  is  a  cause  of  displacement.  This 
is  noticed  among  the  poor  who  do  heavy  work.  The  women  of  In- 
dia, who  were  at  one  time  supposed  to  bear  children  with  ease  and 
impunity,  and  to  suffer  less  from  uterine  affections  than  our  Ameri- 
can women,  are  very  subject  to  complete  i>rolapsus  uteri,  caused  no 
doubt  from  their  want  of  care  after  confinement  and  in  carrying 
heavy  burdens.  General  weakness,  induced  by  exhausting  diseases 
and  extreme  old  age,  affects  the  pelvic  organs  very  decidedly.  This, 
no  doubt,  is  the  cause  of  prolapsus  uteri  in  women  with  consump- 
tion and  in  the  very  aged. 

The  most  important,  certainly  the  most  fre(pient,  causes  of  uter- 
ine displacement  are  the  injuries  and  improper  management  incident 
to  child-bearing.  The  condition  of  the  uterine  snpjiorts  after  partu- 
I'ition  is  that  they  are  all  greatly  enlarged  through  the  growth  of 
gestation,  and,  while  they  are  competent  to  maintain  the  large  uterus 
which  rests  in  the  abdominal  cavity,  they  must  undergo  involution 
in  conjunction  with  the  diminution  of  the  uterus.  If  this  involu- 
tion fails  in  the  uterine  ligaments  and  vagina  while  it  goes  on  in  the 
uterus  the  supports  fail,  l)ecause  they  are  too  long  and  relaxed.  Im- 
perfect involution,  not  only  of  the  uterus  but  of  all  the  other  tissues 
and  organs  of  the  pelvis,  is  seen  to  give  rise  to  displacement.  This 
imperfect  involution  may  be  due  to  post-partum  inflammation  or  to 
the  j)atient  resuming  the  active  duties  of  life  before  involution  is 
completed.  In  regard  to  the  injuries  of  the  pelvic  floor  and  their 
effect  on  the  position  of  the  uterus  the  reader  is  referred  to  the 
chapter  on  that  subject.  , 

Finally,  enlargement  of  the  uterus,  whether  from  imperfect  in- 
volution, inflammation,  or  the  presence  of  neoplasms,  will  cause 
prolapsus.  This  will  occur  although  all  the  supports  may  be  nor- 
mal ;  the  balance  between  the  supports  and  the  organs  to  l)e  su|v 
ported  being  disturbed  by  the  increased  weight  of  the  uterus,  de- 
scent will  occur. 


DISLOCATIONS  OF  THE  UTERUS.  295 

It  should  also  be  borne  iu  uiiiid  that  the  abnormally  large  uterus 
will  prolapse  in  spite  of  the  normal  supports,  while,  on  the  other 
hand,  defective  supports  which  permit  a  normal  uterus  to  descend 
will  ii'ive  rise  to  enlargement  of  the  uterus  by  congestion,  swelling, 
and,  finally,  hyperplasia,  and  by  this  increase  of  weight  will  incline 
it  to  remain  displaced. 


TREATMENT  OF  PROLAPSUS  UTERI. 

There  are  four  important  objects  to  be  attained  in  the  treatment 
of  prolapsus  uteri :  to  restore  the  displaced  organ,  to  keep  it  in  place, 
to  restore  the  supports  of  the  uterus,  and  to  remove  complications 
and  accompanying  affections  if  any  such  exist. 

The  restoration  of  the  uterus  to  its  proper  place  is  performed  as 
follows  :  The  patient  is  placed  in  Sims's  position,  and,  if  the  pro- 
lapsus is  complete,  the  uterus  is  grasped  in  the  lingers,  and,  while 
compression  is  made,  it  is  pushed  upward  in  the  axis  of  the  pelvic 
cavity.  By  these  means  the  displacement  is  reduced  from  the  third 
degree  to  the  second ;  then  the  perinseum  should  be  retracted  with 
Sims's  speculum,  and  with  two  sponges  in  holdei*s  the  uterus  should 
be  raised  to  its  normal  elevation.  Difficulty  in  accompHshing  this  is 
sometimes  caused  by  the  fundus  uteri  turning  backward  while  the 
upward  pressure  is  being  made,  so  that,  in  place  of  overcoming  the 
displacement,  the  prolapsus  is  changed  to  a  retroversion.  This  can 
be  guarded  against  by  making  the  pressm-e  mostly  on  the  posterior 
side  of  the  cervix.  l*assing  the  sound  and  making  it  guide  the 
uterus  in  the  riglit  direction  while  upward  pressure  is  being  made  is 
anotlier  way  of  managing  difficult  cases.  "While  these  manipulations 
are  being  made  the  patient  should  relax  the  abdominal  muscles  by 
avoiding  all  straining.  Many  patients  fail  to  obey  orders  in  this 
respect ;  they  continue  to  hold  the  breath,  and  strain  as  if  preparing 
to  resist  the  pain  of  some  injury  about  to  be  inflicted  npon  them.  I 
have  overcome  tliis  annoyance  by  causing  the  patient  to  take  long 
regular  respirations  while  being  treated.  In  rai'e  cases,  in  which 
much  difficulty  is  met  in  replacing  the  fallen  uterus,  the  patient 
should  be  placed  in  the  knee-chest  position,  and  then  the  chances  are 
that  the  uterus  will  slip  back  to  its  position  without  much  help.  If 
any  aid  is  needed  it  can  be  given  by  the  sponges  in  holders,  or  what 
is  quite  as  good,  if  not  better,  in  manipulating  with  the  patient  in 
this  position,  is  to  use  one  or  two  fingers  in  place  of  the  sponges. 
With  a  very  limited  experience  and  a  knowledge  of  the  methods 
described  any  one  can  manage  this  portion  of  the  treatment.     To 


296  DISEASES  OF   WOMEN. 

keep  the  uterus  in  place  is  tlie  question  wliicli  is  not  easily  settled. 
The  object  of  all  the  mechanical  means  which  may  be  employed  is, 
lirst,  to  keep  the  organ  in  position  and  thereby  give  relief.  At  the 
same  time  through  the  agency  of  the  artificial  support,  and  other 
means,  to  restore  the  natural  supports. 

If  the  prolapse  is  not  beyond  the  second  degree,  and  is  due  to 
relaxation  only  of  the  uterine  supports,  and  not  associated  with  any 
injury  that  destroys  the  integrity  of  the  pelvic  lloor,  the  uterus  may 
be  retained  by  means  of  a  pessary  or  tampon  until  the  supports 
recover  their  original  strength.  In  connection  with  these  mechani- 
cal means,  rest  in  the  recumbent  position  is  one  of  the  most  im- 
portant factors  in  bringing  about  the  desired  result. 

The  material  used  for  the  tampon  should  be  absorbent  cotton  or 
marine  lint.  To  simply  keej)  the  uterus  in  place  the  cotton  is  no 
doubt  the  best.  It  is  soft  and  most  agreeable  to  the  tissues.  When 
there  is  any  vaginitis  or  endometritis  causing  a  free  discharge,  ma- 
rine lint  does  better.  It  takes  up  the  discharge,  disinfects  it,  and 
prevents  decomposition.  This  it  does  better  than  the  cotton.  In 
some  cases  the  lint  is  irritating  to  the  tissues  and  can  not  be  long 
continued.  Sometimes  I  have  alternated  the  use  of  the  cotton  and 
lint  with  much  satisfaction. 

Since  the  introduction  of  antiseptic  material  for  dressings,  the 
tampon  has  been  far  more  useful  in  surgery.  In  the  past  when 
sponges,  not  well  prepared,  were  used,  they  could  be  retained  in 
place  but  a  few  hours  ^vithout  causing  decomposition.  Now  the 
marine  lint  or  borated  cotton  can  be  worn  twenty-four  or  forty-eight 
hours  without  being  offensive. 

For  those  who  have  vaginitis  or  any  inflammation  of  the  uteinis  I 
direct  that  the  tampon  be  applied  in  the  morning  after  having  used 
the  douche  of  hot  water,  plain  or  medicated.  At  night  the  tampon 
is  removed  and  the  douche  again  used  and  afterward  the  tampon  re- 
placed, if  the  uterus  will  not  stay  in  place  without  it,  but  omitting 
it  for  the  night  if  the  recumbent  position  will  overcome  the  tend- 
ency to  displacement.  When  there  is  no  inflammatory  complication 
the  tampon  may  be  left  in  place  two  days  and  a  night.  At  the  end 
of  the  second  day  it  should  be  removed  at  bed-time  and  replaced 
next  morning,  the  douche  being  used  after  removal  and  before  intro- 
ducing it  again. 

Astringents  of  various  kinds  have  been  employed  with  the  t;mi- 
pon,  the  cotton  being  saturated  with  the  solution  to  be  used,  or  the 
agent  may  be  employed  in  powder.  The  latter  is  much  the  prefer- 
able way  when  the  milder  astringents  are  selected.     As  a  rule  I  pre- 


DISLOCATIONS   OF  THE  UTERUS.  297 

fer  the  borated  cotton  or  marine  lint  alone,  using  sucli  astringents  as 
may  be  required  in  the  douche. 

In  many  cases  there  is  some  loss  of  the  pelvic  floor  from  pre- 
vious injury.  This  structure  should  be  restored  as  soon  as  the  tis 
sues  are  in  a  condition  to  warrant  surgical  treatment.  As  a  rule,  in 
those  cases  of  prolapsus  which  have  existed  for  some  time,  the  nu- 
trition of  the  tissues  is  impaired  and  needs  treatment  preparatory  to 
operating.  For  a  more  complete  discussion  of  this  subject  the 
reader  is  referred  to  the  chapter  on  injuries  of  the  pelvic  floor. 

Keeping  the  uterus  in  its  position  by  the  tampon  and  other 
means  of  support  has  the  effect  of  not  merely  relieving  the  prolapsus, 
but  also  of  giving  the  uterine  ligaments  every  chance  to  regain  their 
normal  condition.  Artificial  support  is  palliative  and  curative  as 
well.  The  mechanical  supports  used  in  the  treatment  of  prolapsus 
include  a  variety  of  devices.  The  pessaries  used  are  of  two  kinds — 
those  that  are  placed  in  the  vagina  and  are  held  in  position  by  the 
pelvic  floor,  and  those  that  are  held  in  place  by  being  attached  to  a 
strap  round  the  waist.  The  former  are  applicable  in  the  first  and 
second  degrees  of  prolapsus  while  the  pelvic  floor  remains  normal  or 
nearly  so.  The  latter  are  used  in  complete  prolapsus,  and  in  those 
cases  where  there  is  so  much  loss  of  the  pelvic  floor  that  it  will  not 
keep  the  pessary  in  position.  Whan  the  perinseum  is  sufiicient  to 
support  the  vagina  and  the  prolapsus  is  limited  to  the  flrst  or  second 
degree,  the  instrument  known  as  Peaslee's  pessary  answers  very  well. 
It  is  a  simple  ring  made  of  whalebone  and  covered  with  soft  rubber 
(see  figure).  When  in  position  it  rests  upon  the  pelvic  floor.  It 
should  admit  the  cervix  without  making  pressure  upon  it,  and  should 
fit  the  upper  portion  of  the  vagina  without  distending  it  to  any  ap- 
preciable extent.  It  acts  by  carrying  the  upper  portion  of  the  vagina 
and  the  cervix  backward  into  the  normal  position,  and  at  the  same 
time  raises  the  uterus  to  a  very  slight,  but  sufiicient  extent.  If 
well  adapted  it  takes  off  the  pressure  from  the  lower  part  of  the 
vagina  and  permits  it  to  contract  and  regain  its  tonicity.  Fig.  137 
represents  prolapsus  in  the  second  degree.  Fig.  140  shows  the  pes- 
sary in  position  after  the  uterus  has  been  replaced. 

When  there  is  relaxation  of  the  pelvic  fioor  due  to  the  prolapsus 
it  is  necessary  to  keep  the  patient  at  rest  much  of  the  time  during 
the  first  week  or  two  that  the  pessary  is  worn.  If  this  is  not  prac- 
ticable a  perineal  band  should  be  worn  to  support  the  pelvic  floor 
while  the  patient  is  exercising.  In  the  progress  of  the  treatment 
the  vagina  should  contract  when  the  uterus  is  supported  by  the 
pessary.     This,  in  time,  requires  that  a  smaller  instrument  should  be 


298  DISEASES  OF   WOMEN. 

used.     The  rule  is  tlmt  the  smallest  instrument  should  l)e  em])loyed 
that  will  keep  the  uterus  in  plaee.     If  too  lar«:e  a  pessary  is  used  it 


Fig.  140. — Uterus  replaced,  uith  pessary  in  position. 

will  keep  the  uterus  in  place,  but  will  overdistend  the  vagina  and 
weaken  the  supports  of  the  uterus  in  place  of  restoring  them. 

One  great  advantao:e  which  the  ring  pessary  has  is  in  being 
easily  introduced  or  withdrawn,  and  that  it  does  not  become  displaced 
except  to  settle  downward,  and  this  can  be  easily  corrected  by  the 
patient  assuming  the  knee-chest  position  from  time  to  time. 

AVhen  the  uterus  inclines  to  retrovert  after  having  been  elevated, 
a  common  occurrence,  a  retroversion  pessary  will  act  better  than  the 
ring,  but  the  use  of  that  instrument  will  be  more  fully  discussed 
under  the  head  of  retroversion. 

Prolapsus  occurring  after  the  menopause  when  the  uterus  has 
undergone  final  involution,  may  be  relieved  in  some  cases  by  the  old 
glass-globe  pessary.     It  certainly  is  the  best  instrument  that  I  have 


DISLOCATIONS  OF  THE   UTERUS.  299 

found  for  old  patients  having  prolapsus  of  the  vaginal  walls,  bladder, 
and  the  remains  of  the  atrophied  uterus,  if  the  pelvic  floor  remains 
sufficient  to  support  tlie  pessary.  It  simply  keeps  the  uterus  and 
bladder  up  in  the  pelvis  by  distending  the  vaginal  walls.  The  ute- 
rus may  be  anteverted  or  retroverted,  but  is  so  small  that  it  makes 
no  difference  wliat  position  it  occupies  so  long  as  it  is  kept  high 
enough  up. 

The  globe  is  easily  used.  In  fact  no  mistake  can  be  made  with 
it  except  to  use  one  that  is  too  large.  This  must  be  avoided,  be- 
cause one  that  is  too  large  will  cause  vaginitis  and  ulceration.  It 
is  a  fact  also  that  the  pessary  which  answers  when  first  used  will  be 
too  large  when  the  parts  regain  some  of  their  original  tonicity. 
For  a  time  the  patient  should  be  kept  under  observation  and  the  in- 
strument changed  to  suit.  This  globe  pessary  is  the  most  trouble- 
some instrument  to  remove.  I  have  usually  succeeded  by  using  a 
small  Sims's  speculum  and  a  Sims's  vaginal  depressor,  and  seizing 
the  instrument  between  the  two  and  making  traction.  When  this 
fails,  a  pair  of  miniature  obstetric  forceps  should  be  made  out  of 
strong  copper-wire,  by  doubling  it  to  form  loops  and  twisting  the 
ends  to  make  the  handles.  With  this  the  globe  is  very  easily 
grasped  and  removed.  The  intra- vaginal  pessaries,  such  as  the  ring 
and  globe  already  mentioned,  and  all  others  that  rest  wholly  within 
the  vagina  are  liable  to  slip  down  and  give  the  patient  great  dis- 
comfort, and  sometimes  they  come  away  entirely.  This  is  especially 
the  case  when  first  introduced.  To  obviate  this,  a  perineal  band 
should  be  worn  until  the  peringeum,  upon  which  the  pessary  de- 
pends for  support,  regains  its  tonicity.  By  this  arrangement  the 
same  results  are  obtained  as  by  the  use  of  the  cup  and  stem  j^essary, 
to  be  noticed  hereafter — in  fact,  better  results  so  far  as  the  comfort 
of  the  patient  and  the  final  effects  are  concerned ;  therefore,  I  have 
always  endeavored  to  relieve  prolapsus  when  possible  by  the  intra- 
vaginal  pessary. 

Several  uterine  supporters  have  been  devised  to  meet  the  require- 
ments of  cases  in  which  the  pelvic  floor  is  relaxed  from  long  disten- 
tion, so  that  it  has  not  power  to  sustain  a  pessary  in  position,  and 
the  patient's  circumstances  will  not  permit  long  rest  in  the  recum- 
bent position  and  the  use  of  the  tampon. 

They  are  all  constructed  on  similar  principles  of  mechanism  and 
action — namelj^  cup  and  ring  to  receive  the  cervix  uteri,  and  a  stem 
attached  which  projects  from  the  vagina  and  is  fastened  to  apei'ineal 
band,  which  in  turn  is  attached  to  a  waistband.  The  advantages 
claimed  for  this  kind  of  uterine  supporter  are  that  if  properly  ad- 


300 


DISEASES  OF   WOMEN. 


jn^ited  it  will  certuinly  keej)  the  uterus  in  place,  and  the  j)atient  can 
remove  and  readjust  it  when  desirable.  These  are  valuable  features 
no  doubt,  and  may  be  fairly  claimed  for  the  instrument  as  a  rule, 
but  not  without  many  exceptions.  There  are  cases  where  this  form 
of  instrument,  while  it  will  keep  the  uterus  at  its  proper  elevation, 
will  not  keep  it  in  its  proper  axis  without  very  great  care  in  its  ad- 
justment. Under  such  circumstances  the  patient  can  not  remove  and 
replace  the  pessary  with  any  satisfactory  results.  While  pushing  up 
the  uterus,  during  the  introduction  of  the  pessary,  a  retroversion 
takes  place,  and  wearing  the  instrument  only  aggravates  that  form  of 
displacement.  The  further  objections  which  may  be  placed  over 
against  the  advantages  of  this  kind  of  pessary  are  that  it  can  not 
be  worn  for  any  great  length  of  time  without  doing  harm  and  caus- 
ing great  discomfort,  and  where  in  a  given  case  the  patient  can  not 
adjust  it  properly  herself  it  will  do  more  harm  than  good,  and  should 
not  be  employed  on  any  account  under  these  conditions.  Again,  in 
the  most  favoralile  cases,  it  is  a  constant  source  of  irritation,  less  or 
more.  The  vulva  is  irritated  by  its  presence  and  usually  becomes 
inflamed  in  time ;  the  pressure  of  the  cup  against  the  cervix  and 
upper  end  of  the  vagina  causes  inflammation  and  ulceration,  if  the 
patient  takes  much  active  exercise.  The  reason  for  this  is  that  the 
pessary  is  firmly  fixed  by  its  support  outside  of  the  body  and  the 
movements  of  the  pelvic  organs  against  this  fixed  instrument  cause 
great  friction.  The  intra-vaginal  pessary  moves  with  the  pelvic 
organs,  but  the  stem  pessary  does  not  accom- 
modate itself  to  the  requirements,  and  hence 
its  power  to  do  harm. 

From  the  little  that  has  been  said,  it  will 
appear  that  the  use  of  the  vaginal  stem  pes- 
sary for  the  relief  of  prolapsus  is  most  misat- 
isfactory.     All  that  can  be  said  of  such  means 
of  support  is,  that  in  some  cases  they  may  be 
used  for  a  time  in  the  hope  of   helping  to 
restore   the   natural   uterine    supports.      Dr. 
Paul  F.  Munde  has  truly  said,  "  The  ideal 
pessary  for  complete  prolapsus  uteri  is  yet 
undiscovered."    The  instrument  which  I  have 
found  to  answer  best  of  the  stem  pessaries  is 
a  modification  of  Cutter's  (Fig.  141). 
These  pessaries  should  he  fitted  with  care,  and  just  here  another 
difiiculty  is  encountered  in  the  fact  that  they  are- all  made  of  one 
size  and  shape,  so  that  it  is  diflicult  to  change  them  to  suit  special 


Fig.    141. — Stem  pessary. 
Modification  of  Cutter's. 


DISLOCATIONS   OF  THE  UTERUS.  301 

cases.  This  I  have  tried  to  overcome  by  making  the  stem  flexible, 
or  rather  so  that  it  can  be  molded,  and  capable  of  being  shortened, 
so  that  it  can  be  made  to  suit  each  case. 

Fortunately,  stem  pessaries  are  rarely  needed,  and,  I  may  say, 
that  every  year  I  iind  less  need  for  them. 

By  a  careful  and  judicious  use  of  the  ring  and  the  tampon,  aided 
by  the  T-bandage  to  support  the  pelvic  floor,  one  can  accomplish 
nearly  all  that  can  be  done  by  these  artiflcial  supports. 

The  important  facts  in  connection  with  pessaries  already  men- 
tioned, may  be  recapitulated  here,  and  they  should  be  borne  in  mind. 
They  are  as  follows :  First,  these  means  of  relief  for  prolapsus  most- 
ly are  temporary  and  palliative,  and  can  only  keep  the  uterus  in 
place  until  the  tissues  are  prepared  for  the  operation  of  perineor- 
raphy  when  the  pelvic  floor  has  been  injured  ;  second,  they  keep 
the  uterus  in  place  till  the  normal  supports  are  restored ;  and,  third, 
they  reduce  a  complete  prolapsus  to  an  incomplete,  when  an  intra- 
vaginal  pessary  will  answer  the  purpose. 

While  these  artiflcial  means  of  support  are  being  employed,  ef- 
forts should  be  made  to  strengthen  the  parts  and  to  remove  all  com- 
plications which  tend  to  keep  up  the  prolapsus,  astringent  injections 
should  be  continued,  standing  and  walking  should  be  limited  to  an 
amount  which  is  sufticient  for  exercise,  and  lifting  heavy  weights 
and  wearing  tight  and  heavy  clothing  should  be  avoided.  The  bow- 
els should  be  kept  free,  so  that  straining  at  stool  may  be  unneces- 
sary. This  last  point  should  be  carefully  attended  to.  Constipation 
is  a  potent  cause  in  producing  and  keeping  up  prolapsus.  The  gen- 
eral health  should  be  cared  for,  and  if  there  is  any  debility  it  should 
be  met  by  the  proper  tonic  treatment. 

In  some  of  the  most  favorable  cases  complete  relief  will  be  ob- 
tained by  the  means  described,  so  that  all  mechanical  supports  can 
be  given  up.  Care  should  be  taken  not  to  remove  the  pessary  too 
soon.  I  have  found  in  cases  of  prolapsus  that  it  is  best  to  reduce 
the  size  of  the  pessary  by  changing  from  time  to  time  to  a  smaller 
one. 

Martin,  of  Berlin,  has  reported  one  hundred  and  ninety-two  cases 
in  which  he  has  operated  for  the  cure  of  prolapsus.  In  all  but  six 
he  was  obliged  to  perform  an  operation  upon  the  cervix ;  in  three 
instances  it  was  necessary  to  extirpate  the  entire  uterus.  In  one 
hundred  and  seventy-one  cases  silk  sutures  were  used,  in  seventeen 
the  continuous  catgut,  the  latter  being  highly  commended,  al- 
though it  is  noted  that  it  is  not  safe  to  depend  entirely  upon  these, 
as  secondary  haemorrhage  may  occur  if  they  are  not  re-enforced  with 


302  DISEASES   OF   WoMEN. 

silk.  Relapses  occurred  only  eleven  times,  and  those,  too.  in  old 
subjects.  The  operations  i)erforraed  were  anterior  and  pusteriur 
kolporrliaphy,  Avith  perineorrhaphy. 

In  conn)arint(  my  own  results  with  the  above,  1  find  that  I  have 
succeeded  as  well  by  the  combined  use  of  mechanical  supports  and 
surgical  operations.  That  in  the  treatment  of  prolapsus,  where  o\y 
erating  upon  the  cer^^x  uteri  and  pelvic  floor  has  failed,  kolpor- 
rliaphy has  also  been  useless.  I  have,  therefore,  abandoned  that  op- 
eration. 


TREATMENT  OF  PROLAPSUS  BY  GALVANO-CAUTERY. 

Dr.  John  Byrne,  of  Brooklyn,  has  treated  successfully  nine  c;L<es 
of  prolapsus  of  the  uteiiis  by  galvano-cautery.  In  three,  the  cervix 
uteri  was  completely  amputated  with  the  galvano-cautery.  The 
other  six  were  treated  by  partial  amputation  of  the  cervix.  The  de- 
scription of  the  operation  is  given  by  Dr.  Byrne  as  follows : 

"  A  diverging  double  tenaculum  \vas  passed  into  the  cervical 
canal  and  iixed  in  the  tissues  so  as  to  secure  complete  control  of  this 
part.  The  entire  mass  was  next  returned  within  the  pelvic  cavity, 
and  the  uterus  elevated  sufficiently  to  show  the  line  of  vaginal  in- 
sertion in  its  entire  circumference.  While  in  this  position,  a  small 
platinum  knife,  brought  to  a  red  heat,  was  slowly  carried  around  the 
base  of  the  cervix,  close  up  to  the  vaginal  fold,  and  to  a  depth  suffi- 
cient to  accommodate  a  platinum  loop,  and  to  insure  it  against  slip- 
ping. The  latter  was  next  adjusted,  and  the  amount  of  battery  im- 
mersion being  duly  estimated  to  guard  against  overheating  of  the 
wire,  the  loop  was  slowly  and  with  intermissions  contracted,  until 
about  one  quarter  of  an  inch  in  depth  had  been  reached.  The  wire 
was  now  removed,  and  a  firmly-rolled  tampon,  one  and  a  half  inch 
in  diameter  and  four  inches  long,  smeared  with  glycero-tannin, 
having  four  per  cent  of  carbolic  acid,  was  passed  into  the  vagina, 
and  a  T-bandage  applied." 

Two  of  the  six  cases  required  linear  cauterization  of  the  vagi- 
nal walls  as  well  as  partial  amputation.  The  following  is  Dr. 
Byrne's  description  of  the  operation : 

"  The  parts  having  been  returned  as  in  the  former  case,  the  line 
of  vaginal  insertion  was  noted,  and  merely  marked  in  spots  by  the 
cautery  knife.  The  entire  mass  was  then  brought  do\\Ti  and  out, 
and  with  the  same  instrument  a  deep,  circular  fissure  about  three 
eighths  of  an  inch  in  depth  was  made  around  the  entire  circumfer- 
ence of  the  cervix,  the  knife  being  carried  upward  and  inward  in 


DISLOCATIONS  OF  THE  UTERUS.  303 

the  direction  of  the  os  internum,  and  precisely  as  I  am  accustomed 
to  do  in  suitable  cases  of  carcinoma.  This  being  done,  three  diverg- 
ing fissures  were  made,  one  central,  one  toward  either  side  on  the 
anterior,  and  one  only  on  the  rectal  surface,  starting  from  and  con- 
necting with  the  circular  incision  for  a  distance  of  about  three 
inches  ;  care  being  taken  that  the  entire  depth  of  the  hypurtrophied 
vaginal  membrane  should  be  incised." 

I  am  unable  to  speak  from  experience  regarding  this  method  of 
treating  prolapsus  of  the  uterus.  The  histories  of  the  cases  given 
by  Dr.  Byrne  in  the  "  Transactions  of  the  American  Gynecological 
Society  "  for  188C,  are  very  satisfactory. 


CHAPTER   XVIIL 


KETROVERSIOX    OF    THE    UTERUS. 


Retroversion  of  tlie  uterus  is  a  cliange  in  the  axis  of  tliat  organ 
in  which  the  fundus  points  toward  the  sacrum  and  the  cervix  turns 
toward  the  symphysis  pubis  or  vaginal  outlet.  This  displacement 
varies  in  extent  in  different  cases  ;  three  degrees  are  usually  de- 
scribed. In  the  iirst  degree  the  fundus  points  toward  the  promon- 
tory of  the  sacrum  ;  in  the  second  the  uterus  lies  almost  transversely 
in  the  pelvis ;  and  in  the  third  tlie  fundus  is  low  do^vn  in  the  pel- 
vis, while  the  cervix  is  tlu'own  upward  at  a  higher  elevation  than 
the  fundus. 

Retroversion  is  usually  progressive,  except  in  the  first  months  of 
pregnancy  and  iu  the  puerperal  state.  In  these  conditions  retrover- 
sion may  occur  abi'uptly,  and  so  it  may  under  other  circumstances, 
but  usually  it  comes  on  gradually,  passing  from  the  first  degree  to 
the  second,  and  on  to  the  third. 

It  is  exceedingly  rare  to  find  retroversion  in  the  first  degree  ex- 
isting for  any  length  of  time,  the  displacement  usually  passing  on  to 
the  second  and  third  degrees. 

The  anatomical  changes  which  take  place  in  backward  dis])lace- 
ments  are  to  some  extent  the  same  as  those  found  in  prolapsus. 
The  same  changes  in  the  supports  of  the  uterus  are  found,  and 
though  differing  in  detail  are  the  same  in  kind.  This  arises  from 
the  fact  that  nearly  every  case  of  prolapsus  is  associated  with  more 
or  less  retroversion,  and  in  nearly  all  cases  of  retroversion  there  is 
also  a  slight  prolapsus.  These  changes  have  been  discussed  under 
the  head  of  prolapsus,  hence  it  is  only  necessary  for  me  to  ])oint 
out  here  the  anatomical  features  which  are  particularly  concerned 
in  retroversion. 

In  retroversion  there  is  shortening  of  the  posterior  vaginnl  wall 
by  contraction.  The  exceptions  to  this  are  when  there  is  rectocele, 
and  in  recent  cases  in  which  the  vaginal  wall  is  apparently  short- 


RETROVERSION   OF  THE  UTERUS. 


305 


ened,  but  in  reality  is  thrown    into  folds.     The    anterior   vaginal 
wall  is  generally  distorted  rather  than  displaced.     Its  upper  end  is 


Fig.  142. — The  three  degrees  of  retroversion. 

crowded  upward  and  sometimes  forward  by  the  cervix  nteri,  and  its 
lower  part  is  sometimes  pressed  downward  and  forward,  giving  it 
the  appearance  of  a  urethrocele. 

The  relations  of  the  cervix  and  vagina  are  changed  more  or  less 
in  the  majority  of  cases.  In  some  the  projection  of  the  cervix  into 
the  vagina  is  apparently  very  much  increased  posteriorly.  To  the 
touch  the  vagina  appears  to  be  attached  to  the  whole  length  of  the 
cervix.  This  is  apparent,  not  real,  and  is  usually  found  so  w^hen 
the  vagina  has  still  maintained  its  tonicity.  In  other  cases,  with 
marked  shortening  of  the  vaginal  wall,  the  invagination  of  the  cer- 
vix is  lessened,  Nearly  always  the  invagination  of  the  cervix  ante- 
riorly is  less  than  normal.  The  position  of  the  uterus  as  regards 
elevation  varies  greatly  in  different  cases.  This  may  be  normal  in 
the  pelvis,  simply  changed  in  its  axis,  or  it  may  be  prolapsed  so  that 
the  cervix  is  close  to  the  vulva,  the  anterior  vaginal  wall  being  much 
shortened.  Again,  the  posterior  wall  of  the  uterus  may  rest  upon 
21 


306 


DISEASES   OF   WOMEN. 


the  pelvic  floor  and  altogetlier  l;e  j)laced  I'ar  back  in  the  pelvis,  so 
that  the  fundus  presses  upon  the  rectum,  while  the  bladder  niav  not. 


Fig   143. — Retroversion  of  the  second  degree. 

as  a  rale,  be  much  affected,  either  in  its  position  or  function,  yet  it 
frequently  is.  The  weight  of  the  uterus  being  removed  from  be- 
hind there  is  nothing  except  the  vesical  ligaments  to  prevent  the 
bladder  from  extending  backward  when  distended.  It  then  rests 
upon  the  retroverted  uterus  instead  of  rising  up  towai'd  the  abdomi- 
nal cavity,  and  the  ovaries  and  Fallojiian  tubes  are  to  some  extent  car- 
ried backward  and  downward  with  the  uterus.  The  extent  of  this 
displacement  varies  greatly.  In  some  cases  there  is  complete  pro- 
la})sus  of  one  ovary,  or  of  both  of  these  organs,  so  that  they  lie  in 
the  sac  of  Douglas  and  the  uterus  rests  upon  them.  In  other  cases 
the  ovaries  rest  upon  the  retroverted  uterus.     One  case  of  this  kind 


RETROVERSION   OF  THE  UTERUS.  30Y 

I  well  remember  to  liave  operated  upon.  The  ovaries  were  diseased 
and  gave  so  much  trouble  that  I  decided  to  remove  them.  One  was 
in  its  normal  position,  the  other,  the  rig-ht  one,  was  adherent  to  the 
side  of  the  uterus.  This  prolapsus  of  the  ovaries  is  one  of  the 
worst  com})lications  of  retroversion. 

There  is  a  strongly-prevailing  opinion  that  the  circulation  in  the 
pelvic  organs  is  much  deranged  by  retroversion,  and  that  changes  of 
structure  of  these  organs  follow  in  consequence.  How  far  this  is  a 
fact  it  is  difficult  to  determine.  It  is  true  that  in  nearly  all  cases  of 
retroversion  are  found  some  congestive  inflammatory  trouble  and 
structural  changes,  either  from  degeneration  or  hyperplasia,  but 
whether  these  changes  preceded  the  version  and  perhaps  aided  in 
producing  it,  or  whether  they  resulted  from  the  change  of  position, 
can  not  at  all  times  be  ascertained.  There  is  good  reason  for  be- 
lieving that  all  malpositions  cause  deranged  nutrition  which  in  time 
lead  to  organic  changes,  and  still  such  pathological  conditions  are 
found  when  there  is  no  displacement,  showing  that  these  relations  of 
cause  and  effect  are  interchangeable  in  displacements  and  some  other 
diseases  of  the  uterus. 

COMPLICATION'S. 

There  are  cases  of  retroversion  so  complicated  that  they  are  per- 
manent and  incurable.  These  should  be  clearly  understood  ;  hence 
I  refer  to  them  briefly  in  this  connection. 

There  are  two  classes  of  such  cases :  Those  which  have  had  pel- 
vic peritonitis  wdiile  the  uterus  was  retroverted,  the  adhesions  made 
by  the  products  of  the  inflammation  permanently  fixing  the  uterus 
in  its  malposition.  I  presume  that  a  similar  result  is  sometimes 
produced  by  pelvic  peritonitis,  the  products  of  which  (behind  the 
uterus)  will  by  contracting  drag  the  uterus  into  the  position  of  re- 
troversion. This  complicated  form  of  retroversion  has  been  con- 
sidered incurable,  but  recently  encouraging  efforts  have  been  made 
to  relieve  it  by  surgical  treatment.  This  subject  will  be  referred 
to  and  discussed  at  the  end  of  this  chapter.  The  other  class  is 
one  in  which  a  similar  condition  occurs  as  the  result  of  malfor- 
mation or  congenital  malposition.  In  cases  of  this  kind  the  uterus 
is  retroverted,  the  posterior  vaginal  wall  short  and  rigid,  the  utero- 
sacral  ligaments  are  short  and  rather  unyielding,  and  although  the 
uterus  is  slightly  movable  it  can  not  be  restored  to  its  proper  place. 
In  such  case  the  pelvis  is  wide  and  shallow,  and  there  is  often  a 
lack  of  cellular  tissue  around  the  pelvic  organs.  When  I  first  had 
my  attention    directed  to  this  class  of  cases  I  presumed  that  they 


308  DISEASES   OF   WOMEN\ 

must  liave  had  pelvic  ]K'ritoiutis,  but  in  many  of  tlieni  tliere  w;;8 
no  evidence  obtained  from  the  past  hi.story  to  warrant  any  such 
conclusion.  Further  investi<ijation  satislied  me  that  the  lesions 
were  the  result  of  jierverted  develo])nient  and  fijrowth.  Some  of 
these  cases  do  not  sutfcr  much,  but  they  are  sterile  as  a  nile. 

Sijinplo)iiatol(Kjy. — The  clinical  history  of  retrovei'sion,  so  far  a.< 
the  symptoms  are  concerned,  is  not  sufficiently  definite  to  be  diag- 
nostic. Many  of  the  symptoms  are  common  to  prolapsus  and  cer- 
tain other  affections  of  the  uterus.  Another  curious  fact  is  that 
the  suffering  caused  by  retroversion  varies  greatly  in  different  pa- 
tients. The  rule  is  that  retroversion  causes  much  discomfort,  but  I 
have  seen  one  patient  who  had  retroversion  for  many  yeai-s  and  yet 
was  one  of  the  most  active  women  I  have  ever  known,  and  was  per- 
fectly free  from  all  evidence  of  any  affection  of  the  pelvic  organs. 

The  symptoms  which  belong  more  especially  to  retroversion  are 
rectal  tenesmus  and  the  feeling  of  obstruction  to  a  free  action  of  the 
bowels. 

Backache,  general  pelvic  tenesmus,  aching  of  the  limbs,  irritation 
of  the  bladder  and  rectum,  neuralgic  pains  in  the  pelvis,  and  the 
fact  that  these  symptoms  are  aggravated  by  walking  and  standing 
and  are  relieved  in  the  recumbent  position,  are  all  evidences  of  re- 
troversion, but  also  occur  in  prolapsus. 

Menstniation  is  frequently  deranged  and  menorrhagia,  dysmen- 
orrhoea  of  a  mild  form,  and  irregular  recurrence  of  the  menses,  have 
all  been  traced  to  this  form  of  displacement ;  but  all  these  are  more 
frequently  caused  by  other  affections.  In  several  cases  that  I  have 
seen,  the  menstrual  discharge  was  offensive  and  very  distressing  to 
the  patient.  This  symptom  I  have  noticed  more  frequently  in  retro- 
version and  retroflexion  than  in  any  other  affection  of  the  uterus. 

Physical  Signs. — The  physical  signs  are  obtained  by  the  touch 
and  uterine  sound.  The  vaginal  touch  reveals  the  os  uteri  pointing 
toward  the  introitus  vulvte,  or  in  extreme  cases,  toward  the  sym- 
physis pubis.  The  anterior  vaginal  wall  is  often  found  jirojecting 
downward  in  front  of  the  cervix.  The  upper  portion  of  the  pos- 
terior vaginal  wall  is  found  to  be  pressed  downward  and  forward,  so 
that  the  junction  of  the  posterior  cervical  wall  of  the  uterus  and  the 
vagina  are  much  nearer  to  the  vulva  and  more  easily  touched  with 
the  finger.  In  some  cases  this  prolapsus  of  the  posterior  vaginal 
wall  is  very  marked,  and  appears  to  aggravate  the  version  by  jnish- 
ing  the  cervix  against  the  bladder. 

If  the  bladder  is  empty  and  the  nmscles  of  the  abdomen  are  re- 
laxed, the  bimanual  examination  will  show  that  the  utenis  is  not  in 


RETROVERSION  OF  THE   UTERUS.  309 

its  normal  position,  but  mnst  be  retro  verted,  as  indicated  by  the  signs 
ol)tained  l)_y  the  vi'.ginal  touch.  These  signs  of  retroversion,  while 
(iiiite  reliable,  might,  in  rare  or  complicated  cases,  be  misleading,  so 
tiiat  it  is  well  to  contirm  or  correct  by  the  use  of  the  sound  the  evi- 
dence obtained  by  the  touch.  Placing  the  patient  on  the  left  side 
and  using  Sinis's  speculum,  the  sound  can  be  passed  with  ease,  and 
its  direction  will  show  the  dislocation  of  the  uterus. 

In  doubtful  or  complicated  cases,  when  all  the  evidence  is  needed 
that  can  l)e  obtained,  the  rectal  touch  may  be  employed.  The  finger 
in  the  rectum  can  be  swept  all  around,  the  fundus  and  body  of  the 
utei-us  while  it  lies  low  down  in  the  sac  of  Douglas  in  the  retro- 
vei-ted  state.  The  rectal  touch  can  be  made  more  effective  still  by 
making  the  abdominal  or  vaginal  touch  at  the  same  time.  By  these 
means  of  examination  a  diagnosis  can  be  made  with  the  greatest  cer- 
tainty, and  proof  of  the  accuracy  of  the  diagnosis  may  be  obtained 
by  replacing  the  uterus.  Regarding  the  conditions  which  may  be 
mistaken  for  retroversion  and  the  differentiation  little  need  be  said. 
The  question  which  most  frequently  arises  is  whether  there  is  retro- 
version or  retroflexion.  This  can  always  be  settled  by  the  evidence 
obtained  from  the  physical  signs  already  obtained,  and  the  fact  that 
in  flexion  the  uterus  is  bent  upon  itself,  a  fact  that  is  noticed  by  the 
touch  and  confirmed  by  the  use  of  the  sound. 

Causation. — The  causes  which  produce  prolapsus  uteri  are  ap- 
parently the  same  as  those  which  give  rise  to  retroversion.  The 
reader  may  refer  back  to  the  causation  of  prolapsus  for  the  facts  re- 
garding this  matter.  This  mil  save  repetition.  It  is  clearly  evident, 
however,  that  while  there  may  be  much  in  common  in  the  causation 
of  the  two  forms  of  uterine  displacement,  prolapsus  and  retrover- 
sion, there  must  be  some  difference  in  the  causes  which  produce  such 
different  effects.  This  appears  to  have  been  quite  an  obscure  sub- 
ject, for  I  find  that  the  text-books  are  very  indifferent  in  regard  to 
it.  My  own  observations  lead  me  to  believe  that  the  causes  of  re- 
troversion are  the  loss  of  support  from  morbid  states  of  the  uterine 
ligaments  occuring  while  the  pelvic  floor  remains  normal  or  not 
wholly  useless  as  a  means  of  support,  and  that  prolapsus  is  due  to 
defects  in  the  uterine  supports  and  loss  of  the  pelvic  floor  also.  This 
may  be  stated  in  another  way,  which  will  show  what  this  view  is 
based  upon.  In  the  great  majority  of  cases  of  retroversion  which  I 
have  seen,  the  pelvic  floor  has  not  been  wholly  wanting-,  in  fact,  in 
some  ot  the  cases  it  has  been  quite  normal ;  while  in  prolapsus  it  is 
usually  defective.  It  will  be  easily  understood  that  when  the  sup- 
ports of  the  uterus  are  defective,  especially  the  anterior  Kgaments,  and 


310 


DISEASES  OF  WOMEN. 


the  vagina  and  ])elvic  flour  are  in  tlieir  iioriiial  condition  and  keep 
the  cervix  nteri  in  place,  tlie  tendency  would  be  for  tlie  uterus  to 
fall  backward  into  tlie  retroverted  position. 

Changes  in  the  condition  of  the  cervix  uteri  and  in  its  relations 
to  the  vagina,  have  some  iutluence  in  the  causation  of  retroversion. 
In  those  who  have  had  cellulitis,  after  continenient,  in  the  tissue 
ai-ound  the  cervix  above  the  vagina  the  invagination  of  the  cervix  i- 
lessened,  indeed,  sometimes  obhterated. 

The  vagina  to  the  touch  i> 
like  a  cul<le-sac,  the  entire 
uterus  being  above  the  vagina. 
This  condition  favors  retrover- 
sion. Fig.  144  shows  retrover- 
sion with  imperfect  invagina- 
tion of  the  cervix  uteri  in  a 
patient  who  has  had  cellulitis. 

Laceration  of  the  cervix 
bilaterally  produces  a  similar 
condition  of  imperfect  invagi- 
nation, which  is  often  associated 
with  retroversion.  The  ante- 
rior half  of  the  cerHx  becomes  lost  in  the  anterior  vaginal  wall  and 
the  posterior  part  of  the  cervix  is  apparently  less  prominent  in  the 
vagina,  if  not  really  so.  This  is  more  frequently  seen  where  the 
lateral  lacerations  extend  above  the  vaginal  junction.  Fig.  145  shows 
this  condition. 

In  such  cases  the  state  of  the  cer-snx  has  much  to  do  with  keejnng 
up  the  retroversion,  as  well  as  causing  it.     This  I  have  demonstrated 


Fig.  144. —  Ketroversion  with  imperfect  invag- 
ination of  cervix  due  to  infi;numatory 
products  about  it. 


Fig.  145. — Apparent  imperfect  invagi- 
nation due  to  bilateral  laceration  of 
ccrvi.x  :   c,  c,  lips  of  the  cervix. 


Fig.  Hfi. — The  same  uterus  with  its 
lips  drawn  back  into  place  by 
tenacula. 


KETROVERSION   OF   THE    UTERUS. 


311 


l)y  trying  to  keep  the  uterus  in  place  before  restoring  tlie  cervix,  and 
finding  it  very  difficult,  M'liile  it  was  rpiitc  easy  to  do  so  after  the 
cervix  was  restored.  The  ininiodiate  ctlect  of  operating  was  to  bring 
the  cervix  prominently  into  the  vagina  and  sustain  it  there.  Fig.  14(5 
shows  the  change  effected  in  the  case  represented  in  Fig.  145,  after 
tlie  restoration  of  the  cervix  and  before  restoring  the  retroversion. 

Fui'ther  evidance  is  also  obtained  to  show  that  these  mal-relations 
of  the  vagina  and  cervix,  just  mentioned,  favor  retrcxversion  of  the 
uterus  in  the  fact  that  in  those  cases  in  which  the  cervix  has  been 
amputated,  the  uterus  is  generally  retroverted. 

These  points  I  consider  to  be  of  much  importance  and  of  special 
interest  because  they  are  not,  so  far  as  1  know,  discussed  in  medical 
works  with  reference  to  the  causation  of  retroversion  of  the  litems. 

Treatment. — The  indications  are  to  replace  the  utei*us  and  keep 
it  there,  and,  by  so  doing,  the  supports  of  the  uterus  may  regain 
their  normal  condition,  and  complete  relief  follow.  The  methods  of 
replacing  the  retroverted  uterus  are  to  place  the  patient  on  the  left 
side,  and  through  Sims's  speculum  to  raise  the  body  of  the  uterus 
up  with  two  sponges  in  holders,  used  as  in  Fig.  147. 

By  upward  press- 
ure the  uterus  can 
be  raised  as  far  as 
need  be,  or  as  far  as 
possible,  and  then 
one  of  the  spong- 
es should  be  with- 
drawn or  placed  in 
front  of  the  cervix, 
and  backward  press- 
ure made  there. 
This  helps  to  com- 
plete the  replace- 
ment, and  at  the 
same  time  holds  the 
uterus  in  place, 
while  the  sponge  is 
removed  from  its 
position  behind  the 
uterus. 

To  succeed  in  this 
operation,  it  is  ne- 


FiG.  147. — The  three  steps  in  replacing  the  retroverted  uterus 
by  means  of  sponge-holders. 


cessary  to  have  the 


312  DISEASES   OF  WOMEV. 

bladder  empty,  and  that  the  patient  should  not  resist  the  effort- 
of  the  surgeon  to  replace  the  uterus.  Wiien  there  is  any  ditticultv 
met  in  the  ])raetice  of  tlie  method  described,  tlie  patient  sliould  Ix- 
placed  in  the  knee-chest  position  (see  Fig.  150j,  and  the  Sims'.- 
speculum  used.  This  alone  is  sufficient  in  some  ca.ses  to  effect  re- 
jilacement.  AVhen  it  does  not  do  so,  the  upward  pressure  of  the 
sponges  behind,  or  drawing  the  cervix  back  \dth  a  tenaculum,  will 
accomplish  thg  object,  or  both  sponge  and  tenaculum  may  be  used. 

It  is  sometimes  difficult  to  replace  the  uterus  in  cases  of  long 
standing,  owing  to  the  contraction  of  the  posterior  vaginal  wall. 
The  changes  in  the  parts  which  have  taken  place  to  accommodate 
the  malposition,  can  not  always  be  immediately  overcome.  In  such 
cases  all  tiiat  can  be  accomplished  is  to  raise  the  uterus  as  far  toward 
its  normal  place  as  possil)le,  and  then  hold  it  there  by  means  of  a 
temporary  support.  By  the  use  of  the  cotton  tampon  or  a  pessary, 
all  that  is  gained  by  the  first  and  succeeding  efforts  to  replace  the 
uterus  is  kept,  and  if  the  pessary  is  used  properly  it  will  make  con- 
tinuous upward  pressure  upon  the  fundus  uteri,  and  thereb}'  con- 
stantly gain  more  and  more.  In  cases  of  long  standing  the  displace- 
ment becomes  completed  by  slow  degrees,  as  the  tissue  changes  in 
the  support  of  the  uterus  and  vagina  have  taken  place  as  the  result 
of  long-continued  influences,  and  they  can  not  be  aljniptly  rectified. 
It  takes  time  to  imdo  that  which  it  has  required  months  and  years  to 
do;  hence,  the  process  of  restoration  must  be  accomplished  by  degrees 
and  by  repeated  efforts.  The  details  of  this  method  of  treatment 
^-ill  be  given  in  the  clinical  histories  of  cases  to  be  related  hereafter. 

The  next  object  to  l)e  attained  is  to  keep  the  uterus  in  position. 
This  raises  the  question  of  the  mechanical  supports  of  the  uterus.  I 
think  that  Dr.  Frank  P.  Foster,  of  Xew  York,  has  given  the  most 
rational  discussion  of  the  subject  that  I  have  seen,  and  I  will  quote 
his  views  later  on. 


THE  TREATMENT   OF  RETROVERSION    BY  THE   USE   OF 

PESSARIES. 

There  are  a  great  many  kinds  of  pessaries  employed  in  treating 
retroversion  of  the  uterus.  A  few  of  them  can  be  made  to  do  much 
good  when  skillfully  employed.  The  great  majority  of  them  are 
useless,  and  all  of  them  are  capable  of  doing  much  harm  if  used 
without  a  clear  idea  of  how  they  should  be  used.  During  a  discus- 
sion of  displacements  of  the  utenis  at  a  meeting  of  the  A.merican 
Gynecological  Society  held  in  Boston,  in  1S77,  Dr.  E.  R.  Peaslee 


RETROVERSION   OF  THE   UTERUS.  313 

expressed  himself  in  favor  of  tlie  use  of  j^essaries,  claiming,  at  the 
same  time,  to  have  obtained  very  gratifying  results  from  tlieir  use 
in  his  own  practice.  In  the  same  discussion,  Dr.  W.  L.  Atlee  said  : 
"  I  have  had  no  experience  with  pessaries,  at  least  with  their  intro- 
duction, l)nt  I  have  had  a  very  long  experience  with  their  removal. 
I  do  not  think  that  there  is  a  day  when  I  am  at  home  and  in  my 
oflice,  that  I  do  not  have  the  privilege  of  taking  out  a  pessary.  I 
have  removed  pessaries  of  all  forms  and  sizes,  and  pessaries  intro- 
duced by  the  most  distinguished  men  of  the  profession."  Peaslee 
and  Atlee  were  certainly  two  members  of  the  profession  of  this 
country,  equally  distinguished  in  abihty,  profound  judgment,  and 
thorough  honesty,  and  why  they  should  hold  such  oi3posing  views 
upon  a  subject  so  practical  may  not  be  capable  of  explanation  by 
any  one.  It  has  appeared  to  me,  however,  that  the  one  came  to  his 
conclusions  from  a  careful  investigation  of  the  utility  of  j)essaries 
when  properly  used,  while  the  other  based  his  opinions  upon  the 
fact  that  as  generally  employed,  pessaries  do  very  great  hann. 
Viewing  the  subjects  from  these  two  stand-points,  both  conclusions 
are  perfectly  rational,  and  ample  proof  may  easily  be  obtained  of 
the  good  and  evil  which  come  from  the  use  of  these  instruments. 

At  the  present  day,  I  presume  that  if  the  harm  done  should  be 
l^laced  opposite  the  good  accomplished  by  all  the  pessaries  in  use, 
the  results  would  be  about  equally  balanced.  It  follows,  then,  that 
as  matters  stand  at  this  moment,  it  is  a  question  whether  the  human 
race  would  be  better  or  worse  if  all  the  pessaries  were  put  out  of  ex- 
istence. 

The  all-important  fact  remains,  however,  that  pessaries  are  of 
great  value,  and  capable  of  giving  relief  to  those  who  suffer  from 
some  of  the  forms  of  uterine  displacements,  if  properly  used.  The 
same  may  be  said  of  nearly  all  valuable  agents  employed  for  the  re- 
lief of  suffering.  That  any  agent,  capable  of  giving  relief  when 
skillfully  employed,  is  likely  to  be  as  potent  for  evil  when  misused, 
is  a  well-known  fact ;  hence,  the  object  should  be  to  attain  to  a  more 
perfect  and  general  knowledge  of  how  to  make  and  use  pessaries  in 
order  to  promote  the  good  results,  and  lessen  the  evil. 

There  are  many  difficulties  which  naturally  arise  in  the  investi- 
gation of  the  use  of  pessaries.  Not  only  do  authorities  differ  very 
widely  in  their  views  regarding  their  use,  but  one's  own  experience 
is  oftentimes  misleading.  For  example,  a  pessary  may  be  used  to 
correct  a  displacement,  and  marked  relief  is  obtained.  The  patient 
testifies  to  the  fact  that  her  symptoms  are  relieved  and  her  useful- 
ness extended  while  wearing  a  pessary,  and  yet  that  instrument  may 


314:  DISEASES   OF   WOMEN". 

1)0  doiiii^  harm  by  still  further  dainagiiig  tlic  supports  of  the 
uterus. 

These  may  appear  like  contradictory  statements,  and  yet  such  are 
the  facts  observed  many  times  in  practice.  The  same  thing  is  seen 
in  the  abuse  of  corsets.  The  lady  who  has  contracted  her  waist  by 
tight  lacing  suffers  great  discomfort  when  she  goes  without  corsets, 
and  is  relieved  by  wearing  them,  and  yet  no  one  doubts  tlie  fact  that 
great  injury  is  caused  by  this  article  of  wearing-apparel. 

The  mechanical  action  of  pessaries  must  necessarily  be  clearly 
understood  in  order  that  they  may  be  emj)loye(l  with  favorable  re- 
sults; misunderstanding  on  this  point  is  no  doubt  the  cause  of  much 
unsatisfactory  practice.  Judging  from  the  many  errors  made  in  the 
use  of  pessaries,  as  seen  in  practice  and  from  tlie  various  o])inion8 
expressed  by  writers,  I  am  fully  satisfied  that  this  part  of  the  subject 
is  not  as  clearly  understood  as  it  should  be  by  the  profession  gener- 
ally. Mj  own  views  are  so  fully  in  accord  witli  those  of  Dr.  Foster, 
that  I  shall  quote  his  article : 

"  It  can  not  be  said  that  opinions  are  wholly  agreed  as  to  the  way 
in  which  vaginal  pessaries  most  commonly  effect  changes  in  the 
situation,  form,  and  attitude  of  the  uterus.  Those  who  have  given 
any  considerable  amount  of  thought  to  the  matter  will  probably  ad- 
mit (1)  that  a  pessary  may  operate  by  virtue  of  mere  lateral  disten- 
tion of  the  vagina,  being  itself  too  bulky  to  escape  readily  from  the 
pelvic  outlet,  and  thus  preventing  the  parts  resting  upon  it  from  so 
escaping ;  (2)  that  the  pressure  exerted  by  a  pessary  may  be  trans- 
mitted directly  to  the  body  of  the  uterus,  lifting  it  up  when  ante- 
verted  or  retroverted,  as  the  case  may  be  ;  and  (3)  that  such  pressure 
may  operate  by  dragging  the  lower  portion  of  the  organ  in  a  certain 
direction,  thus  causing  its  upper  portion  to  move  in  the  opposite 
direction. 

"  While  there  can  scarcely  be  a  doubt  that  each  one  of  these 
methods  of  action  may  explain  the  work  done  by  pessaries  under 
certain  circumstances,  it  may  be  not  only  interesting  as  a  mere 
matter  of  curiosity,  but  profitable  as  tending  to  greater  precision  in 
practice,  to  inquire  into  the  relative  frequency  with  which  the  one 
or  the  other  actually  operates,  which  of  them  is  therefore  of  the 
greater  practical  importance,  and  which  of  them  should  be  specially 
emphasized  in  teaching.  The  question  as  to  whether  certain  pes- 
saries act  as  levers,  or  whether  they  are  merely  forced  bodily  in  a 
certain  direction,  and  so  fulfill  their  purpose,  is  quite  foreign  to  this 
inquiry,  and,  therefore,  I  shall  not  enter  upon  its  considerations. 

"  In  regard  to  the  method  of  action  first  mentioned — that  of  lateral 


RETROVERSION  OF  THE   UTERUS.  315 

or  transverse  distention  of  the  vagina — it  may  simply  be  said  to  apply 
only  to  special  forms  of  pessaries,  which,  although  in  common  use 
before  Hodge's  time,  liave  now  ahnost  fallen  into  disuse — deservedly, 
I  may  be  allowed  to  add. 

"  The  second  method,  that  of  pressure  transmitted  directly  to  the 
body  of  the  uterus,  is  undoubtedly  the  one  that  is  most  prominent 
in  men's  minds,  most  taken  into  account  in  practice,  and  most  ap- 
pealed to  in  teaching.  And  yet,  it  seems  to  me,  its  scope  is  really 
quite  hmited,  and  its  practical  importance  ahnost  nil.  If  an  ex- 
treme mal  posture  of  the  uterus  is  corrected  by  the  act  of  inserting 
a  pessary  adapted  to  the  case,  as  may  often  enough  be  done,  the  in- 
strument may  act  at  iirst,  I  admit,  by  direct  transmission  of  its  press- 
ure to  the  body  of  the  organ  lifting  the  latter  from  a  state  of  ex- 
treme anteversion  or  retroversion,  as  the  case  may  be.  But  such 
action  is  only  momentary ;  long  before  it  could  restore  the  uterus  to 
its  normal  attitude  another  agenc}^  is  called  into  play,  so  that  when 
the  full  action  of  the  pessary  is  attained,  its  pressure  is  no  longer 
transmitted  to  the  body  of  the  organ.  In  any  case,  then,  this  direct 
action  on  the  body  of  the  uterus  is  of  but  momentary  duration,  and 
accomplishes  but  a  partial  result ;  and,  if  the  malposture  is  not 
originally  very  decided,  or  if  it  is  corrected  before  the  instrument  is 
inserted  into  the  vagina,  it  does  not  come  into  play  at  all. 

"  These  statements  embody  no  novelty,  but  they  are  so  at  variance 
with  the  views  that  seem  to  be  held  by  the  most  influential  teachers 
of  gynecology,  that  it  seems  best  to  put  forward  some  reasons  for 
them.  To  illustrate,  then,  suppose  a  case  of  retroversion.  In  order 
that  a  pessary  may  fully  restore  the  uterus  to  its  normal  attitude, 
and  hold  it  in  such  attitude  (acting  all  the  time  by  direct  pressure  on 
the  body  of  the  organ),  its  pressure  must  be  exerted  not  only  upward, 
but  forward,  and  that,  too,  at  a  point  situated  high  in  the  pelvis. 
Now,  from  my  own  experience,  from  observation  of  the  practice  of 
others,  and  from  the  drawings  employed  by  authors  to  illustrate  the 
action  of  pessaries,  I  believe  that  pessaries  long  enough  to  fulfill 
these  conditions  are  seldom  if  ever  used.  Granting,  however,  that  I 
may  be  mistaken  in  this  respect,  it  will  scarcely  be  disputed  that 
either  such  a  pessary,  besides  being  very  long,  must  have  a  very 
pronounced  curve  in  order  to  enable  its  middle  portion  to  lie  wholly 
below  the  face  of  the  cervix  while  its  upper  end  exerts  the  pressure 
in  question  (in  which  case  its  introduction,  supposing  the  perinteum 
to  be  intact,  would  be  well-nigh  impossible) ;  or  else  its  limbs  must 
diverge  to  such  an  extent  as  to  accommodate  the  cervix  between 
them,  making  the  instrument  very  broad,  in  which  case  it  would  not 


316  DISEASES  OF  WOMEN. 

pass  Letween  the  two  iitero-Racral  ligaments  without  stretching  tliem 
apart  to  such  a  degree  as  practically  to  shorten  them,  thus  causing 
them  to  pull  the  lower  portion  of  the  uterus  backward,  and  conse- 
quently throw  its  upper  portion  forward.  The  result  of  this  latter 
state  of  things  would  be  that  the  retroversion  would  Ije  corrected 
before  the  upper  end  of  the  instrument  had  been  forced  high  enough 
to  restore  the  body  of  the  uterus  to  its  normal  position  by  direct 
l^ressure  upon  it,  or  by  ])ressure  directly  transmitted  to  it.  Further 
than  this,  1  believe  that  in  the  great  majority  of  instances  the  mere 
upward  and  backward  jjressure  upon  the  posterior  vault  of  the 
vagina  would  suffice  to  drag  the  cervix  lJack^yard  in  the  same  way 
before  the  instrument  had  penetrated  at  all  into  the  space  included 
between  the  utero-sacral  ligaments.  This,  however,  would  depend 
upon  the  degree  of  tonicity  with  which  the  vagina  was  endowed. 

"  With  regard  to  anteversion  the  case  is  even  stronger,  while  at 
the  same  time  it  is  simpler,  for  the  anterior  wall  of  the  vagina  is 
naturally  tense,  and  its  tension  is  usually  heightened  by  the  mere 
fact  of  the  uterus  being  in  a  state  of  anteversion.  In  this  tense 
condition  of  the  anterior  vaginal  wall  we  have  a  marked  contrast 
with  the  posterior  wall ;  the  latter  is  much  longer  than  a  straight 
line  drawn  between  its  two  extremities,  and  its  lower  end  is  con- 
nected with  parts  that  are  comparatively  mobile  ;  the  former  is  firmly 
attached  to  the  pubic  arch.  By  reason  of  this  tension  of  the  an- 
terior wall  of  the  vagina,  its  virtual  shortening  occurs  almost  at  once 
whenever  any  notewortliy  pressure  is  made  upon  it :  hence,  any  of 
the  various  forms  of  anteversion  pessaries  that  are  supposed  to  act 
by  lifting  the  body  of  the  uterus  directly  up,  really  accomj^lish  its 
ascent  by  stretching  the  anterior  wall  of  the  vagina,  and  thus  drag- 
ging the  cervix  forward.  In  proof  of  this  statement,  witness  the 
insignificant  size  of  the  anterior  projections  of  these  instruments — 
projections  utterly  incapable  of  reaching  to  the  height  that  they 
would  have  to  reach  in  order  to  make  direct  pressure  upon  the  body 
of  the  uterus,  even  with  the  bladder  intervening,  when  the  organ 
had  approached  anywhere  near  its  normal  position.  The  great  sen- 
sitiveness of  the  anterior  vaginal  wall  to  pressure,  the  well-known 
liability  of  ulceration  to  occur  upon  it  under  the  pressure  of  a  pes- 
sary, both  point  to  its  greater  tension  as  compared  with  the  posterior 
wall. 

"  Passing  now  to  the  third  of  the  various  methods  of  action  that  I 
have  attributed  to  pessaries — that  of  traction  upon  the  lower  portion 
of  the  uterus — but  little  need  be  said  about  it,  for  the  considerations 
brought  forward  to  show  the  limited  scope  of  the  direct-pressure 


RETROVERSION   OF   THE   UTERUS. 


317 


theorv,  all  conspire  to  advance  the  traction  theory  to  the  most  im- 
portant position.  Such  I  believe  it  ought  to  occupy,  unless  the 
statements  I  have  put  forth  are  shown  to  be  erroneous,  I  will 
simply  add  that  always  in  anteversion,  and  usually  in  retroversion,  it 
is  througli  the  medium  of  the  vaginal  wall,  in  my  opinion,  that  pes- 
saries make  traction  upon  the  cervix. 

"  I  will  briefly  mention  some  of  the  practical  applications  of  the 
doctrine  I  have  sought  to  uphold.  In  cases  of  retroversion  it  is 
usually  sufficient  if  pessaries  are  to  be  used  at  all,  to  employ  an  in- 
strument simply  with  the  idea  of  making  backward  pressure  upon 
the  posterior  wall  of  the  vagina,  directing  the  pressure  somewluit 
upward,  unless  there  are  special  reasons  for  not  doing  so,  but  not 
resorting  to  pessaries  with  such  an  exaggerated  pelvic  curve  as  to 
render  their  introduction  difficult.  If  the  instrument  is  cur\ed 
rather  sharply  at  a  point  very  near  its  upper  end,  the  pressure  will 
be  distributed  more  evenly  over  the  posterior  vault  of  the  vagina, 
and,  therefore,  will  be  borne  better. 

"  The  usual  forms  of  retroversion  pessaries  (the  Hodge  instrument 
and  its  various  modilications,  including  those  with  external  support) 
seem  to  me  to  act  in  this  way,  and 
to  be  as  unobjectionable  as  any  we 
are  likely  to  hit  upon.  More  or 
less  stretching  of  the  posterior 
vault  of  the  vagina  is  apt  to  re- 
sult, but  it  is  of  little  consequence 
even  should  it  prove  permanent, 
for  it  in  no  wise  interferes  with  the 
natural  functions  of  the  parts. 
Broad  pessaries,  penetrating  between  the  utero-sacral  ligaments, 
should  never  be  used,  for  these  ligaments  form  a  part  of  the  mech- 
anism by  which  the  normal  situation  and  attitude  of  the  uterus  are 
maintained,  and  anything  that  stretches  and  relaxes  them  interferes 
with  tlie  permanent  cure  of  retroversion." 


G.T/EMANN  &C0 


Fig.  148. — Albert  Smith  pessary. 


ADAPTATION    OF   PESSARIES. 

The  adaptation  of  pessaries  for  the  relief  of  retroversion,  is  facili- 
tated by  keeping  in  mind  the  object  to  be  accomplished,  and  the  way 
in  which  the  instrument  acts  in  fulfilling  these  requirements.  All 
that  remains,  then,  is  to  shape  the  pessary  to  the  case  in  hand,  and 
to  place  it  in  position  after  the  uterus  has  been  restored  to  its  place. 
This  is  an  easy  or  difficult  task,  according  to  the  artistic  and  me- 
chanical skill  of  the  surgeon.     Badly -adjusted  pessaries  are  not  so 


318  DISEASES   OF   WOMENT. 

coiniuon  as  badly-fitting  shoes  and  clothes,  because  they  are  not  so 
generally  used.  No  one  wIkj  is  destitute  of  some  knowL'dge  and 
skill  in  uiechanics,  will  ever  succeed  in  the  treatment  of  displace- 
ments of  the  uterus  by  means  of  mechanical  supports.  The  gravest 
errors  are  committed  every  day  by  using  pessaries  without  under- 
standing the  principle  of  their  action  or  the  methods  of  adapting 
them.  This  lack  of  knowledge  and  of  the  required  ability  lead  to 
the  too  frequent  use  of  certain  kinds  of  pessaries  known  by  the 
names  of  their  inventors.  The  prevailing  idea  being  that  a  certain 
form  of  pessary  recommended  by  some  one  in  authority  will  answer 
for  all  cases,  a  slight  variation  in  size  being  all  that  is  necessary. 
This  is  certainly  a  great  mistake.  The  only  pessary  which  can  be 
of  service  is  one  that  is  correctly  adjusted  to  the  patient  who  is  to 
wear  it ;  not  a  ready-made  one  with  a  distinguished  name  and  repu- 
tation. An  abundant  experience,  so  far  as  seeing  and  treating  many 
cases  goes,  and  some  practical  knowledge  of  the  mechanical  art,  en- 
ables me  to  say,  that  no  two  cases  of  displacement  are  alike,  and, 
therefore,  each  one  must  be  fitted  with  a  pessary  of  the  special  form 
and  size  required.  This  really  simplifies  practice  greatly,  because  it 
enables  one  to  reject  the  vast  number  and  variety  of  ready-made 
pessaries  in  the  market,  and  to  choose  the  simplest  forms  and  adapt 
them  according  to  certain  principles  and  the  recjuirements  of  cases. 
In  the  books  there  is  no  end  to  the  number  of  instruments  com- 
menfled,and  the  directions  to  introduce  and  remove  them  are  ample 
and  suflicient,  but  there  is  a  conspicuous  absence  of  any  delinite  and 
useful  directions  regarding  the  manner  in  which  such  instruments 
are  to  be  fitted. 

In  the  simpler  cases  when  the  uterus  can  be  restored  to  its  posi- 
tion completely,  and  when  thus  restored  the  vaginal  walls  assume 
their  normal  shape,  the  pessary  is  easily  adapted.  The  length  of  the 
vagina  should  be  obtained  from  the  posterior  fornix  to  a  point  cor- 
responding to  the  upper  end  of  the  urethra,  and  the  wiilth  of  the 
vagina  at  that  part  indicated  by  a  line  bisecting  the  center  of  the 
cervix  uteri  should  be  taken.  These  measurements  give  the  size  of 
the  pessary  required  in  length  and  width,  and  are  usually  taken 
through  a  Sims's  speculum,  w^th  the  patient  on  the  left  side. 

The  longitudinal  measurement  is  easily  obtained  by  a  sponge  ajid 
holder  (Fig.  1-iO),  which  are  carried  up  by  the  side  of  the  cervix  to 
the  upper  termination  of  the  vagina,  and  there  marking,  with  the 
finger  resting  on  the  stem  of  the  sponge  holder,  the  ])oint  opposite 
the  junction  of  the  bladder  and  the  urethra.  The  transverse  meas- 
urement may  be  taken  by  sight,  or,  if  the  eye  is  not  trained  suffi- 


RETROVERSION   OF  THE   UTERUS. 


319 


cicntly  for  this,  hy  a  pair  of  long  drcpsing-forceps  having  a  mark  on 
the  haiidlus  tlio  same  distance  from  tlie  lock  as  the  point  of  the 
blades.      The   for- 
ceps are  passed  up 
and  the  blades  ex- 
panded until    they 
reach     the     lateral 
walls  of  the  vagina, 
and,  while  held  in 
this    position,    the 
measurement  is  ob- 
tained from  the  ex- 
tent of    separation 
of  the  handles.  The 
size  being  obtained, 
the  shape  next  de 
niands       attention. 
The  outlines  of  the 
Albert   Smith  pes- 
sary (Fig.  148)  are 
adapted  to  the  lat- 
eral  vaginal    walls 
in   a  general  way, 
and  any  change  to 
suit  special  cases  is 


Fig.  149. — The  method  of  measuinng  the  length  of  the  pes- 
sary ;  p,  retracted  perineal  body. 


easily  made.  The  curves  for  the  antero-posterior  walls  are  shght 
modifications  of  the  ogee  curve  of  the  mechanic,  which  is  two  seg- 
ments of  a  circle  joined 
and  reversed.  This  shape 
may  be  taken  as  a  basis 
from  which  changes  of 
form  must  be  made  in 
every  instrument  used. 

The  guide  for  the  form 
of  these  curves  I  have  ob- 
tained in  this  way  :  I  first 
ascertain  by  touch  and  in- 
spection the  length  of  the 
invagination  of  the  cer- 
vix posteriorly,  and  then 
make   the    posterior  up- 


anterior 
vaginal 
w*il 


Fig.  150. — Diagram  of  pessary  in  situ  on  looking  at 
it  in  Sims's  position,  through  Sims's  speculum. 


ward  curve  of  the  pessary  a  little  short  of  the  extent  of  this  in- 


320 


DISEASES   OF   WOMEN. 


Fig.  151.- 


-Slight  invagination  of  cervix  posteriorly  with 
suitable  pessary. 


vacillation.  The  an- 
terior downward  curve 
is  made  about  etjual 
to  the  posterior,  nub- 
ject  to  slight  varia- 
tions to  meet  special 
cases. 

Figs.  151  and  152 
6ho\v  two  cases  dif- 
fering in  the  extent 
of  invagination,  with 
pessaries  adapted  to 
them. 

These  rules  for  the 
adaptation  of  pessaries 
are  only  useful  as  a 
basis  to  start  from  ; 
each  case  requires  one 
deviation  or  more  from 
these  rules.  This  ne- 
cessitates a  material  for  a  pessary  which  is  easily  molded,  and  this  is 
happily  now  afforded  in  the  instrument  made  of  whalebone  and  fine 
copper-wire,  and  then  covered  with  soft  rubber.  This  kind  of  a 
pessary  can  be  modeled 
with  the  greatest  facility 
to  any  form. 

To  restate  in  full,  yet 
briefly,  all  the  important 
points  in  the  management 
of  mechanical  supports  in 
the  treatment  of  retrover- 
sion I  would  say  that  my 
method  is  as  follows  : 
Sims's  position  and  his 
speculum  are  used  in  re- 
placing the  uterus,  and 
wheti  it  is  restored  the 
measurements  are  taken, 
a  pessary  selected  of  the 
proper  size  and  modeled 
to  suit  as  nearly  as  pos- 
sible.     It   is   then  intro- 


FiG.  152. — Decided  invagination  of  cervix  posteriorly 
fitted  with  a  suitable  pessary. 


RETROVERSION   OF  THE  UTERUS.  321 

(liicecl  and  careful  observations  made  to  see  if  it  fulfills  the  require- 
ments. If  it  does  not  it  is  removed,  altered,  and  reapplied,  care 
being  taken  never  to  have  the  instrument  large  enough  to  make 
general  pressure  on  the  vaginal  walls,  nor  of  such  shape  that  it  will 
make  undue  pressure  at  any  one  point. 

Where  possible,  I  prefer  to  introduce  and  remove  pessaries 
through  Sims's  speculum.  The  method  of  doing  this  is  very  sim- 
])le.  In  the  introduction  the  perinseum  is  retracted,  and  the  pessary 
turned  up  on  tlie  edge  is  passed  beyond  the  vulva  and  then  turned 
half  round,  which  brings  it  into  position. 

It  is  usually  the  case  that,  in  the  treatment  of  retroversion,  the 
pessary  rerpiires  to  be  changed  in  shape  quite  frequently  during  the 
lirst  two  or  three  weeks  that  it  is  in  use,  but  with  the  material  de- 
scribed this  is  easily  done.  When  the  uterus  is  well  in  place,  and 
the  vagina  no  longer  appears  to  be  undergoing  any  changes  from 
involution  and  contraction,  then  a  hard-rubber  pessary  is  made,  using 
the  soft  one,  which  has  been  made  to  answer  the  purpose,  as  a  model. 
The  hard  rubber,  of  course,  can  be  worn  a  much  longer  time  than 
the  soft,  and  is  much  more  agreeable  to  the  tissues. 

In  regard  to  the  modiiications  to  be  made  in  pessaries,  to  suit 
eases  as  they  present  themselves,  all  that  is  necessary  will  be  said 
when  giving  the  histories  of  cases.  It  is  important,  however,  to 
keep  in  mind  what  has  been  said  in  regard  to  the  cases  in  which  the 
uterus  can  not  be  fully  restored  to  its  normal  position,  owing  to 
changes  in  the  posterior  vaginal  wall  and  the  uterine  ligaments.  •  In 
such  cases  the  restoration  to  the  normal  position  must  be  gradual, 
and  hence  the  use  of  the  pessary  is  to  keep  the  uterus  in  the  posi- 
tion in  which  it  is  placed  by  the  efforts  at  restoration,  and  by  the 
support  of  the  instrument  to  favor  a  tendency  toward  the  normal 
position  on  the  part  of  the  uterus.  In  the  management  of  such 
cases  the  posterior  part  of  the  pessary  should 
not  be  much  curved  upward,  if  at  all,  be- 
cause the  object  is  to  have  the  pessary  carry 
the  posterior  vaginal  wall  backward  behind 
and  below  the  uterus  to  support  the  body 
and  fundus,  while  the  cervix  resting  be- 
tween the  bars  of  the  pessary  is  unsupported 
and  free  to  sink  downward  and  backward  Fig-  1 53.— What  the  pessary 
as  the  body  of  the  uterus  rises.     Here  the 

principle  of  the  lever  acts  to  change  the  axis  of  the  uterus.  This 
is  shown  in  Figs.  154  and  155. 

The  lever  action  of  the  pessary  is  made  more  effective  by  the 
22 


322 


DISEASES   OF   WOMEN". 


post, 
vag-. 

wall 


Fig. 


154. — How  the  pessary  acts — shown  by 
the  arrows  in  the  diagram. 


pressure  of  the  l)ladder  and  the  anterior  vaginal  wall  upon  the  ante- 
rior part  of  the  instrument,  which  incline.s  to  raise  the  posterior  part 

uj)ward,  and  so  brini;  the  j)essa- 
ry  into  a  more  oblique  position 
as  tlie  uterus  rises.  See  Fifr, 
154. 

The    ])essary   being   wed<j;e- 
shaped  —  that    is,    narrower    in 
,ant.      front  than  behind — is  held  up- 
w»ii   ward  by  the  contraction  of  the 
lower    portion   of    the    vagina, 
and  the  wedge-action  helps  the 
lever-action   of   the   pessary   to 
raise  the  uterus  and  throw  it  forward. 

In  regard  to  the  surgical  operations  employed  in  the  management 
of  retroversion,  I  may  say  that,  where  the  cervix  uteri  is  lacerated, 
it  should  be  restored,  and  also  that  the  pelvic  floor,  if  injured,  must 
be  operated  upon  in  order  to  care  retroversion.  In  fact,  very  little 
progress  can  be  made  in  the  treatment  of  retroversion,  unless  the 
pelvic  floor  and  uterus  are  normal  or  nearly  so. 

This  is  all  the  surgical  treatment  that  I  now  employ,  besides 
mechanical  support,  in  the  management  of  these  displacements. 

In  recent  times,  Alexander,  of  Liveq^ool,  has 
devised  a  plan  for  the  correction  of  uterine  dis- 
l^lacements,  which  consists  in  shortening  the 
round  ligaments.  In  his  presentation  of  the 
subject,  to  the  British  Gynecological  Society, 
he  said  that  the  operation  has  now  been  per- 
formed in  nearly  all  prominent  cities  in  the 
world,  and  by  most  operators  with  more  uniform 
success  than  generally  befell  any  new  operation. 
He  never  found  any  difiiculty  in  finding  and 
drawing  out  the  ligaments.  An  incision  was 
to  be  made  upward  and  outward  from  the  pu- 
bic spine,  in  the  direction  of  the  inguinal  canal, 
for  one  and  a  half  to  two  or  three  inches,  according:  to  the  fat- 
ness  of  the  subject.  A  considerable  thickness  of  subcutaneous  fat 
was  then  met  with,  which  must  be  cut  through  by  sub-'^ecpient  incis- 
ions, until  the  pearly,  glistening  tendon  of  the  external  oblique 
muscle  was  reached.  Midway  through  the  fatty  tissue  an  aponeu- 
rosis sometimes  appeared,  so  firm  and  smooth,  that  it  might  cause 
the  operator  to  think  he  was  deep  enough,  but  he  would  find  no  liga- 


FlG. 


155. — Second  step; 
the  uterus  falls  into 
the  pessary. 


RETROVERSION   OF   THE   UTERUS. 


323 


nients  at  this  spot.  The  first  stage  of  the  operation  consisted  simply 
in  cutting  down  upon  the  tendon  of  the  external  oblique  muscle, 
until  it  appeared  clean  and  shining  at  the  bottom  of  the  wound. 


Fig.  156. — The  knee-chest  position — air  enters  the  vulva,  v.,  and  distends  the  vagina,  and 
the  fundus  falls  in  the  direction  of  the  arrow. 


The  external  ring  was  then  found.  The  finger  passed  to  the  bottom 
of  the  wound  detected  the  spine  and  the  ring  outside.  Having  iso- 
lated the  external  wound,  and  tied  any  little  vessels,  the  next  step 
was  to  find  the  end  of  the  ligament.  By  everting  all  the  structures 
upward,  the  round  ligament  could  be  seen,  generally  at  the  lowest 
part,  and  with  the  white  easily  distinguished  genital  branch  of  the 
genito-crural  nerve  along  its  anterior  surface  and  close  to  it.  The 
ligament  at  this  stage  was  more  or  less  rounded  in  shape.  It  was  an 
easily  recognized  flesh-colored  structure.  When  the  ligament  was 
identified,  the  small  nerve  on  its  surface  was  to  be  cut  through 
without  dividing  any  of  the  ligament.  Then  gentle  traction  was  to 
be  made,  either  by  the  fingers  or  by  broad,  blunt-pointed  forceps. 
Bands  holding  it  to  neighboring  structures  were  cut  through  with 
scissors.  As  soon  as  it  began  to  peel  out,  it  was  left,  and  the  oppo- 
site side  begun.  The  final  stage  of  the  operation  consisted  in  placing 
the  uterus  in  position  by  the  sound,  and  pulling  out  the  ligaments 
until  they  were  felt  to  control  that  position.  A  curved  threaded 
needle,  with  fine  catgut,  was  used  to  stitch  each  ligament  to  both 
pillars  of  the  ring  and  the  external  abdominal  ring  was  closed  with- 
out strangulating  the  ligament  as  it  lay  between  them.  The  ends  of 
the  ligaments  were  now  cut  off,  and  the  remainder  stitched  into  the 
wound  by  means  of  the  sutures  that  closed  the  incision.     A  fine 


324  DISEASES  OF   WOMEN. 

drainage-tube  was  inserted,  and  the  wound  washed  out  with  carbolic 
or  other  lotion  before  these  sutures  were  tied. 

The  after  treatment  consisted  in  rest.  The  tubes  were  removed 
on  the  second  day,  when  the  wound  was  dressed.  The  mortality  of 
the  operation  miglit  be  set  down  as  nothing.  Three  deatlis  liad  oc- 
curred, but  they  were  due  to  preventable  causes.  As  mortality  did 
not  seriously  enter  into  any  consideration  of  the  result??  of  this  opera- 
tion, the  real  question  at  issue  was  whether  it  fulfilled  the  intentions 
of  the  operator  and  satisfied  the  expectations  of  the  patient.  The 
operation  was  designed  to  correct  certain  uterine  displacements,  and 
these  alone.  Whether  the  discomfort  of  the  patient  would  be  there- 
by reheved,  entirely  depended  on  whether  or  not  the  symptoms  were 
due  to  the  displacement.  To  secure  success,  the  operation  must  be 
properly  performed,  and  the  after  treatment  must  be  rational,  so  that 
no  strain  might  be  placed  on  the  ligaments  until  sound  union  had 
taken  place. 

Most  excellent  results  from  this  operation  have  been  rejiorted  by 
many  surgeons.  I  have  not  practiced  it,  for  the  reiison  that  the 
cases  which  are  curable  by  Alexander's  operation  are  curable  by  the 
means  which  I  liav^e  described,  and  the  cases  that  are  incurable  by 
such  means  are  also  incurable  by  Alexander's  operation. 

Further  experience,  however,  may  prove  that  the  shortening  of 
the  round  ligaments  will  cure  retroversion  more  promptly  and  per- 
manently than  any  other  method  of  treatment,  but  up  to  the  present 
time  that  question  is  not  fully  settled. 

Retroversion  with  fixation  of  the  uterus  from  adhesions  has  been 
considered  incurable,  as  already  stated.  Recently  some  valuable 
contributions  have  been  made  on  this  subject.  Such  cases  have 
been  treated  by  laparotomy,  breaking  up  the  adhesions  and  restoring 
the  uterus  to  its  place. 

Prof.  W.  M.  Polk  has  given  the  results  of  his  labors  in  this  field, 
in  a  most  valuable  paper,  pul^lished  in  the  "  American  Journal  of 
Obstetrics,"  for  June,  18ST,  from  which  I  make  the  following  quo- 
tations : 

"  Laparotomy  for  adherent  retrofiexed  or  retroverted  uterus, 
A.  "W".,  aged  thirty-eight.  This  patient  has  suffered  from  pelvic 
pain  for  several  years.  The  originating  cause  was  obscure,  but  it 
seemed  to  have  been  due  to  pelvic  inflammation,  induced  by  treat- 
ment for  posterior  displacement  of  the  uterus.  Examination  showed 
that  the  uterus  was  retroverted  and  bound  down.  Sensitive  masses 
were  discovered  on  both  sides  of  the  uterus  in  the  broad  ligament 
regions.     Upon  opening  the  abdomen,  the  remains  of  pelvic  peri- 


RETROVERSION   OF  THE   UTERUS.  325 

toiiitis  were  evident.  The  uterus  was  fixed  in  the  cul-de-sac. 
Chronic  salpingitis  and  periovaritis  were  present  on  both  sides,  the 
tubes  and  ovaries  being  attached  to  the  posterior  face  of  the  broad 
Hoanients,  but  not  to  the  pelvic  Hoor. 

"  The  adhesions  binding  down  the  uterus  were  separated  and  the 
tube  and  ovary  upon  the  left  side  removed,  after  which  the  mass 
upon  that  side  could  no  longer  be  felt.  The  appendages  upon  the 
right  side  were  not  disturbed,  owing  to  the  accidental  wounding  of 
a  vessel  close  to  the  uterus.  There  was  prolonged  and  very  trouble- 
some bleeding.  By  the  time  this  was  controlled  I  did  not  think  it 
wise  to  further  prolong  the  operation,  the  patient's  condition  forbid- 
ding it.  This  case  aifordedme  an  opportunity  to  study  the  behavior 
of  an  inflamed  tube  after  the  adhesions  binding  it  down  and  crip- 
pling it  had  been  torn  up.  I  carefully  freed  the  right  tube  and 
ovary  from  the  adhesions  binding  them  to  the  posterior  face  of  the 
broad  ligament,  and  satisfied  myself  that  they,  as  well  as  the  append- 
ages on  the  left,  represented  the  mass  felt  in  this  region  through  the 
vagina.  I  used  a  drainage-tube,  as  there  had  been  a  good  deal  of 
manipulation  in  the  pelvis.  This  served  the  additional  purpose  of 
keeping  the  uterus  forward 

"  The  patient  remained  in  the  hospital  nearly  two  months,  and 
when  I  examined  her  just  before  her  departure  I  found  both  sides 
of  the  uterus  free  from  the  masses,  and  from  sensitiveness  as  well. 

"  Mrs.  A.,  aged  twenty-six.  Seven  years  ago  had  a  severe  at- 
tack of  pelvic  inflammation  ;  she  was  very  ill  for  three  mouths,  and 
then  made  a  gradual  recovery.  The  prominent  local  condition  dur- 
ing the  attack  was  a  mass  in  the  left  iliac  region.  This  slowly  dis- 
appeared, but  ever  since  the  illness  she  has  been  conscious  of  uneasi- 
ness in  that  region.  From  the  date  of  the  inflammatory  attack  to 
the  present,  she  has  suffered  severe  dysmenorrhoea,  this  pain  lasting, 
as  a  rule,  for  three  days,  and  of  sufficient  intensity  to  compel  her  to 
keep  in  a  recumbent  posture  during  its  continuance.  Aside  from 
this  menstrual  pain,  the  soreness  in  the  left  iliac  region,  and  an  occa- 
sional attack  of  rhematism,  she  has  been  in  good  health. 

"  Two  months  ago  she  was  married,  since  which  she  has  been  a 
constant  sufferer  from  pelvic  pain,  with  much  increase  in  the  dys- 
menorrhoea. Upon  examination,  I  found  the  uterus  retroflexed  and 
firmly  bound  in  Douglas's  cul-de-saG ;  the  body  enlarged  and  very 
sensitive.  Upon  the  left  side,  in  the  broad  ligament  region,  there 
was  a  flxed  sensitive  mass,  about  as  large  as  a  walnut ;  upon  the  right, 
in  the  corresponding  region,  a  similar  but  smaller  mass  was  likewise 
detected. 


! 


326  DISEASES   OF   -WOMEN.  j 

'■'■Diagnosis. — Tletroflexed,  adherent  uterus,  witli  adlierent  tii])e8 
and  ovaries ;  the  whole  the  i-esult  of  a  prior  salpingitis  and  j)eritoui- 
tis.  I  advised  laparotomy,  and  in  March  it  was  done.  The  adc 
hesioiis  l)inding  the  utems,  tiihes,  and  ovaries  were  easily  broken  up 
and  those  or<;ans  liberated.  The  tube  walls  were  somewhat  thickene(L 
but  there  was  no  distention  of  the  cavities.  The  rip^ht  ovary  vrm 
small,  the  left  somewhat  enlarged ;  this  one  M'as  much  more  firmly 
and  extensively  adherent  than  the  right.  A  drainage-tube  wai 
placed  in  position,  as  usual,  behind  the  uterus,  and  the  wound  wal 
closed.  The  patient  made  a  good  recovery,  and  has  had  one  meoi* 
struation  free  of  pain. 

"  The  uterus,  to-day,  is  in  normal  position,  with  the  exception  that 
it  is  somewhat  lower  in  the  pelvis  than  I  would  |;refer.  It  is  now 
movable,  and  it,  together  with  the  appendages,  is  as  free  from  pain 
on  pressure  as  could  be  possible  so  soon  after  operation. 

"  B.  C,  aged  thirty-one.  Married,  and  has  h;id  four  children.  At 
the  birth  of  the  last,  live  years  ago,  had  an  attack  of  pelvic  inflamma- 
tion. This  left  her  ^vith  dysmenorrhoea,  backache,  and  constipation ; 
sexual  intercourse  also  became  painful.  These  symptoms  had  con- 
tinued to  date. 

"  Wearying  of  the  various  efforts  at  cure  to  which  she  had  been 
subjected,  she  sought  relief  in  an  operation.  Inquiry  showed  that 
short  of  the  operation,  her  treatment  had  been  thoroughly  and  care- 
fully conducted.  She  stipulated  that  her  ovaries  should  not  be  re- 
moved. 

"  Examination  showed  the  uterus  in  an  extreme  state  of  retro- 
flexion, enlarged,  very  tender,  and  firmly  fixed  in  the  cul-de-sac  of 
Douglas.  On  either  side  of  the  uterus  were  sensitive  masses,  evi- 
dently the  tubes  and  ovaries. 

"  The  abdomen  was  opened,  and  a  hood  of  false  membrane  was 
found  extending  from  the  anterior  face  of  the  uterus  over  the  fun- 
dus to  the  rectum  and  the  posterior,  lower  portion  of  the  pelvis,  thus 
firmly  imprisoning  the  uterus.  This  was  torn  away  and  the  organ 
was  lifted  into  its  normal  position.  The  tubes  and  ovaries  upon  both 
sides  w^ere  adherent,  and  they  corresponded  to  the  masses  wdiich  had 
been  found  by  vaginal  examination.  They  were  next  torn  free. 
The  tubes  were  thickened,  but  their  cavities  appeared  not  to  be  en- 
larged. 

"  The  pelvis  was  now  washed  with  warm  water.  A  Hegar  drain- 
age-tube was  inserted,  and  the  wound  was  closed.  A  Ilodge  pessary 
was  next  placed  in  the  vagina.  The  patient  could  not  tolerate  the 
pessary,  so  it  was  removed  the  following  day.    When  it  was  removed, 


RETROVERSION   OF  THE   UTERUS.  327 

the  drainage-tube  was  found  to  have  slipped  from  its  position,  and 
the  uterus  was  more  retro  verted,  but  not  retroflexed,  the  end  of  the 
tube  resting  upon  the  fundus. 

"  It  was  conchided  that  the  operation  was  a  failure,  but  when  at 
the  end  of  a  week  (from  the  operation)  a  sound  was  introduced,  and 
it  was  proved  that  the  uterus  was  not  adherent,  but  could  be  lifted 
as  far  forward  as  it  had  been  at  the  section,  it  was  determined  to 
liold  it  forward  by  shortening  the  round  ligaments.  This  was  done 
on  the  fourteenth  day  from  the  section,  the  uterus  easily  coming 
into  place. 

"  At  the  end  of  two  months  the  patient  was  discharged,  the  uterus 
was  in  normal  position ;  she  had  menstruated  twice  without  pain, 
the  constipation  and  backache  were  each  a  thing  of  the  past. 

"  M.  F.,  aged  thirty -three,  has  had  seven  children.  Sixteen  months 
ago  she  had  a  miscarriage  which  was  followed  by  symptoms  of  jDel- 
vic  inflammation.  From  that  time  up  to  date  she  has  had  excessive 
and  painful  menstruation,  excessive  backache,  and  constipation. 
Examination  showed  an  extreme  degree  of  retroflexion,  the  fundus 
enlarged  and  very  sensitive,  the  entire  organ  firmly  fixed  in  the  cul- 
de-sac  of  Douglas,  ill-defined  sensitive  spots  in  both  broad  ligament 
regions.  The  operation  was  done  while  the  patient  was  menstru- 
ating. The  uterus  was  bound  down  by  adhesions,  these  were  easily 
separated,  the  tubes  and  ovaries  were  then  freed  from  those  which 
imprisoned  them.  Upon  bringing  the  tubes  to  the  surface  they 
were  found  swollen,  the  right  one  occluded,  and  both  containing 
menstrual  blood. 

"  In  the  presence  of  the  house  staff.  Dr.  Fordyce  Barker  and  Dr. 
Harvie,  of  Danville,  Ya.,  the  occlusion  of  the  right  tube  was  opened 
up,  both  tubes  were  washed  out  with  warm  water,  and  they,  with 
the  ovaries,  which  were  sound,  were  replaced  in  the  pelvic  cavity. 
A  Hegar  tube  was  next  introduced,  and  the  abdominal  wound  was 
closed.  The  patient's  condition  being  good,  the  round  ligaments 
were  next  shortened,  the  combined  operation  consuming  about  fifty 
minutes.  The  patient  made  an  uninterrupted  recovery,  and  at  the 
end  of  eight  weeks  was  discharged  cured.  Uterus  in  nonnal  posi- 
tion and  no  sensitive  spots  above  it.  The  three  patients  thus  re- 
ported each  made  an  easy  recovery.  The  lessons  learned  from  the 
last  of  the  series  are  more  numerous,  and  by  far  the  most  interest- 
ing, especially  if  it  is  read  in  conjunction  with  the  suggestions  as  to 
the  treatment  of  this  class  of  cases." 


328 


DISEASES   OF    WOMEN. 


RETROFLEXION   OF   THE    UTERUS. 

In  the  chapter  on  anteflexion  of  the  uterus  tlie  pathology  of 
flexions  generally  was  discussed,  and  the  classifleation  adopted  was 
that  flexion  was  a  deformity  and  not  a  simple  dislocation.  In  fact, 
a  very  broad  distinction  was  made  between  displacements  and  flex- 
ions. It  was  observed  at  the  same  time,  that  retroflexion  of  the  uterus 
was  frequently,  in  fact  in  the  great  majority  of  cases,  produced  as  a 
result  of  a  retroversion.  The  uterus  flrst  becomes  displaced  back- 
ward, and,  in  consequence  of  the  deranged  forces  acting  upijn  the 
uterus,  it  becomes  bent  upon  itself — that  is,  flexed  as  well  as  dis- 
placed. Owing  to  this  close  association  of  retroversion  and  retro- 
flexion, and  the  fact  that  the  treatment  of  both  has  nmch  in  com- 
mon, I  have  placed  them  together. 

In  practice  I  have  made  out  two  degrees  of  retroflexion,  and  the 
flexion  is  confined  to  the  body,  the  cervix  maintaining  its  normal 

relations  to  the  vagina. 
At  all  events  the  cer- 
vix is  never  bent  back- 
ward. 

Pathology.  —  This 
is  the  same  as  in  ante- 
flexion, so  far  as  the 
uterus  is  conceraed. 
There  is  a  want  of 
suflicient  tissue  at  the 
junction  of  the  cervix 
and  body  of  the  utcnis, 
the  point  where  the 
flexion  occurs.  In  the 
majority  of  cases  the 
cei'vix  and  upper  part 
of  the  vagina  are 
farther  forward  in  the 
pelvis  than  they  should 
be,  and  the  cervix 
points  forward  more  than  it  should,  but  less  so  than  in  retrovei-sion. 
This  gives  rise  to  a  little  shortening  of  the  anterior  vaginal  wall,  or 
else  an  undue  invagination  of  the  anterior  wall  of  the  cervix. 

Symptomatology. — The  symptoms  present  in  retroflexion  are  very 
much  the  same  as  those  of  retroversion,  hence  it  is  only  necessary. 
here  to  note  some  few  that  are  more  marked  in  flexion  than  in 


Fig.  157. — Fibroid  on  posterior  wall  of  uterus  simulatin 
retroflexion. 


RETROVERSION   OF   THE    UTERUS. 


329 


version.  In  retroflexion  the  menstrual  function  is  more  frequently 
disturbed.  Dy.snienorrlicea  is  often  present,  and  although  the  })ain8 
are  less  acute  than  in  anteflexion,  they  are  far  more  marked  than 
in  retroversion.  In  many  of  those  having  retroflexion  the  men- 
strual dis(!harge  is  often  quite  offensive;  this  also  occurs  in  other 
conditions,  but,  taken  in  connection  with  other  signs  and  symptoms, 
it  is  valuable  as  a  means  of  diagnosis  in  this  affection. 

Physical  Signs. — The  points  of  difference  between  retroflexion 
and  retroversion  are,  as  observed  by  the  touch,  that  the  cervix  in 
flexion  does  not  point  toward  the  vulva  or  pubes,  but  is  nearly  in  its 
normal  position.  There  is  less  relaxation  of  structure  of  the  upper 
portion  of  the  vagina.  Behind  the  cervix  the  rounded  fundus  can 
be  felt  by  the  examining  finger  to  be  pointing  downward  and  back- 
ward, instead  of  directly  backward  as  in  retroversion.  Between  the 
cervix  in  the  vagina  and  the  fundus  uteri  the  angle  of  flexion  can 
be  felt.  All  this  can  be  made  out  by  the  vaginal  touch,  and,  in 
favorable  cases,  the 
bimanual  examination 
will  help  to  verify 
the  signs  obtained. 

When  the  abdom- 
inal muscles  are  very 
lax  and  the  vagina 
long  and  elastic  the 
uterus  can  be  carried 
upward  with  the  fin- 
ger which  is  in  the 
vagina,  and  brought 
within  reach  of  the 
hand  on  the  abdomen 
— i.  e.,  the  uterus  can 
be  grasped  and  exam- 
ined bi  manually.  In 
that  case  the  defor- 
mity of  the  uterus  can 
be  clearly  made  out ; 
but  it  is  rare  that  this 

is  practicable.  It  is  usually  impossible  to  reach  the  anterior  wall 
of  the  uterus  by  the  hand  placed  upon  the  abdominal  muscles.  In 
the  great  majority  of  cases  I  have  been  obliged  to  depend  upon  the 
vaginal  touch  and  the  uterine  sound  to  make  a  positive  diagnosis. 

The  two  conditions  which  I  have  found  simulating  the  physical 


Fig.  158. 


Prolapsed  and  adherent  ovary  simulating  retro- 
flexion. 


330  DISEASES  OF  WOMEN. 

signs  are  a  large  and  prolajxsed  ovar}'  and  a  su])pcritoneal  fibroma 
on  the  posterior  wall  of  the  uterus.  These  are  shown  in  Figs.  1.j7 
and  158. 

In  either  of  these  affections  the  touch  gives  the  signs  of  retro- 
flexion, and  it  is  only  by  using  the  sound  and  proving  that  the 
uterus  is  in  its  proper  position  and  form  that  they  can  be  distin- 
guished from  flexion.  While  the  sound  is  not  absolutely  necessary 
to  differentiate  between  retroflexion  and  such  conditions  as  those 
named,  I  find  that  it  gives  confidence  in  the  diagnosis  in  retroflexion 
to  pass  it  and  see  that  the  canal  runs  backward  and  is  not  distorted 
by  the  flexion. 

Sometimes  it  is  very  difficult  to  pass  the  sound  around  the 
point  of  flexion,  and  in  order  to  do  so  it  may  be  necessary  to  raise 
up  the  fundus  and  also  the  cervix,  in  order  to  straighten  the  canal. 
When  the  uteras  is  very  tender,  much  care  should  be  exercised  in 
using  the  sound.  The  application  of  cocaine  is  useful  in  relieving 
the  hypergesthesia. 

Causation. — Retroflexion  occurs  in  single  women,  and  also  in 
those  who  have  borne  children.  In  tlie  former,  I  have  found  it 
much  more  frequently.  For  practical  purposes,  this  affection  might 
be  divided  as  regards  causation  into  two  forms,  congenital  and  ac- 
quired. From  the  history  of  those  cases  in  which  this  flexion  is 
found  in  early  life,  I  believe  that  it  is  brought  about  by  some 
lesion  of  development.  It  may  not  be,  strictly  speaking,  a  con- 
genital malformation.  It  is  more  likely  that  the  infantile  uterus 
becomes  retroverted  before  puberty,  and  then  when  secondary 
development  takes  place,  the  increase  in  weight  of  the  body  and 
fundus  causes  displacement  of  the  upper  part  of  the  uterus,  and 
the  cervix  being  held  in  place  by  the  resistant  vagina,  the  flexion 
is  produced.  This  is  the  only  explanation  of  the  production  of 
these  cases  at  puberty.  When  it  is  acquired  after  bearing  chil- 
dren, I  believe  that  retroversion  occurs  first,  and  if  the  cervix 
meets  resistance  from  the  anterior  vaginal  wall  and  bladder  in 
front,  the  flexion  is  produced.  If  the  uterus  is  made  to  bend  a 
little  at  the  point  of  flexion,  the  pressure  at  that  point  will  cause 
atrophy  at  that  point,  and  thereby  the  flexion  will  gradually  in- 
crease. 

It  is  possible  that  in  some  of  the  acquired  cases  there  is  some 
lesion  or  excess  of  involution  at  the  junction  of  the  body  and  cer- 
vix, and  the  walls  of  the  uterus  being  thus  weakened  at  that  point, 
permit  the  uterus  to  fall  over  backward. 

Prognosis. — In  acquired  cases,  and  uncomplicated,  appropriate 


RETROVERSION   OF   THE   UTERUS. 


331 


treatment  wiJl  usually  give  relief  if  persisted  in  long  enough.  In 
the  so-called  congenital  forms,  there  will  be  found  cases,  which  do 
not  yield  to  treatment.  Kelief  from  the  most  distressing  symptoms 
may  be  obtained,  but  as  soon  as  the  mechanical  support  is  removed 
the  flexion  will  return.  The  resistance  of  some  cases  to  treatment 
I  have  found  due  to  a  rigid  state  of  the  posterior  wall  of  the  va- 
gina, which  prevents  the  use  of  a  pessary  which  would  extend  far 
enough  back  to  throw  the  fundus  forward.  In  such  cases  the  use  of 
a  pessary  often  aggravates  the  trouble. 

Treatment. — The  principles  of  treatment  in  retroflexion  are  the 
same  as  in  retroversion,  and  hence  need  not  be  discussed  here,  fur- 
ther than  to  note  some  of  the  additional  means  necessary  in  flexion. 

To  restore  the  uterus  to  its  normal  form  and  position  it  is  often 
necessary  to  use  the  Elliott  adjuster,  and  to  repeat  its  use  a  number 
of  times ;  then  a  pessary  should  be  employed  as  in  retroversion.  In 
adjusting  the  pessary,  care  should  be  taken  not  to  curve  the  poste- 
rior bar  too  much,  but  to  shape  it  so  that  it  will  carry  the  posterior 
vaginal  wall  back  behind  the  body  and  fundus  so  as  to  support  both. 
This  can  be  made  clear,  perhaps,  by  showing  the  effect  of  a  pessary 
which  is  not  of  proper  shape,  and  which  increases  the  flexion  by 
making  pressure  upward  in  place  of  backward  (Fig,  153), 

Alexander's  operation  is  suggested  to  the  mind  by  those  cases 
which  do  not  yield  readily  to  treat- 
ment, and  I  presume  it  would  be  use- 
ful. However,  the  only  cases  which 
resist  the  usual  treatment  are  those 
in  which  the  posterior  vaginal  wall 
is  unyielding,  and  the  uterus  can  not 
be  straightened  by  Elliott's  adjuster. 
In  such  cases  there  is  reason  to  sup- 
pose that  the  uterus  is  fixed  in  its 
malposition  by  some  old  cellulitis  or 
peritonitis  ;  and  if  so,  Alexander's 
operation  would  not  succeed. 

It  is  rather  rare  that  the  treat- 
ment prescribed  fails.  In  obstinate 
cases  in  which  the  frequent  straightening  of  the  uterus  does  not 
stimulate  the  growth  of  tissue  at  the  point  of  flexion,  the  stem 
pessary  should  be  tried. 

The  canal  of  the  cervix  should  be  dilated  sufficiently  to  admit  a 
fair-sized  glass  or  hard-rubber  stem.  The  stem  is  then  introduced 
to  overcome  the  flexion  and  keep  the  uterus  straight,  and  the  pessary 


Fig.  159. — Extreme  retroflexion 
(Barnes). 


332 


DISKASES   OF   WOMEN. 


is  used  to  keep  the  stem  in  place.  The  same  kind  of  stem  and 
pessary  as  are  used  in  the  treatment  of  antetiexion  arc  employed, 
with  this  dilference,  that  the  pessary  is  adapted  to  keep  the  uterus 
in  position  as  well  as  to  hold  the  stem  in  place. 

To  recapitulate,  the  stem  corrects  the  flexion,  and  the  pessary 
corrects  the  retroversion,  as  well  as  keeping  the  stem  in  place. 

Atrophy  of  the  Uterine  Walls  at  the  Junction  of  the  Body  and  Cer- 
vix. —  This  is  a  condition  which 
causes  anteflexion  and  retroflexion, 
which  may  alternate  by  turning  the 
body  of  the  uterus  backward  or  for- 
ward. 1  have  found  it  in  those  who 
have  borne  children,  and  also  in 
those  who  have  not. 

Pathology. — There  is  a  defect  in 
the  middle  layer  of  the  anterior  and 
posterior  walls  of  the  uterus  at  the 
internal  os  which  permits  the  uterus 
to  bend  forward  or  backward  with 
equal  facility.  Fig.  IGO  shows  the 
appearance  of  such  a  uterus.  Such 
cases  are  rare,  and  have  a  clinical 
liistory  very  much  the  same  as  ante- 
flexion. I  can  give  the  best  descrip- 
tion of  the  affection  by  relating  the  history  of  a  well-marked  case. 


Fig.  160. — Uterus  wiili  defective  walls; 
the  supra-vaginal  ]jortion  of  the  cer- 
vix is  elongated  (after  Winckel). 


ILLUSTRATIVE    CASE. 

A  dressmaker,  single,  and  in  fair  general  health,  twenty-seven 
years  old,  came  under  my  care  in  the  hospital,  giving  the  following 
history :  She  began  to  menstruate  at  flfteen,  and  from  that  time 
until  she  entered  the  hospital,  had  suffered  from  dysmenorrha?a. 
The  pain  at  her  periods  l)ecame  progressively  worse,  until  she  was 
entirely  unfltted  for  her  duties. 

She  sought  relief  in  medicine,  but  only  large  doses  of  opium 
sufficed.  Becoming  wholly  useless,  she  entered  one  of  the  hosi)itals 
of  tliis  city,  and  remained  imder  treatment  there  for  four  months. 
During  that  time  she  had  violent  hysterical  convulsions  at  her  men- 
strual periods,  and  deriving  no  benefit  from  treatment  was  dismissed 
as  incurable.  Upon  examination,  I  found  marked  anteflexion  of 
the  body  of  the  uterus ;  and,  owing  to  slight  stricture  of  the  internal 
OS  and  the  extreme  tenderness  of  the  uterus,  the  sound  could  not 
be  passed  until  she  was  anaesthetized.      I  then  found  that  the  os 


RETROVERSION   OF  THE   UTERUS.  333 

internum  was  constricted.  I  incised  it  and  dilated  until  I  could 
pass  a  No.  1>  English  sound.  At  the  same  time  I  used  Elliott's  ad- 
juster to  straighten  the  uterus,  and  cariied  tlie  fundus  backward. 
This  was  accomplished  with  unusual  facility,  the  uterus  making  no 
resistance  to  bending  in  any  dii-oction.  The  instrument  was  with- 
drawn, and  the  patient  placed  in  bed  to  rest ;  there  was  no  pain 
or  inflammation  following  this  treatment.  Three  days  afterward  I 
made  a  digital  examination,  and  found  the  uterus  retroflexed.  By 
using  again  tlie  Elliott  adjuster  I  was  able  to  change  the  retroflex- 
ion back  to  the  original  anteflexion,  which  remained  so  for  several 
days.  It  being  necessary  to  pass  the  sound  every  third  day  to  pre- 
vent the  recurrence  of  the  stricture  at  the  internal  os,  1  took  advan- 
tage of  the  opportunity,  by  changing  the  flexion  a  number  of  times, 
and  found  that  whatever  position  I  placed  the  body  of  the  uterus  in, 
it  would  remain  there. 

The  dilatation  of  the  os  externum  gave  the  patient  great  relief 
from  the  dysmenorrhosa.  The  usual  treatment  for  congestion  and 
hyperaesthesia  was  continued,  and  the  canal  kept  dilated  by  the  use 
of  the  sounds.  A  stem  pessary  was  tried,  but  she  could  not  tolerate 
it  except  by  keeping  in  bed.  She  improved  so  much  in  two  months 
that  she  left  the  hospital,  and  only  returned  occasionally  as  an  out- 
patient. For  two  years  I  kept  her  under  observation  and,  although 
she  was  not  entirely  free  from  pain,  she  was  able  to  make  her  living. 

In  this  case  I  feel  sure  that  the  trouble  originated  in  an  imper- 
fect growth  at  the  time  of  secondary  development. 

In  one  other  case  of  which  1  have  full  notes,  the  flexion  came 
after  the  patient's  second  confinement,  and,  perhaps,  was  due  to  a 
derangement  of  involution. 


CHAPTER   XIX. 


ABUSE     OF     PESSARIES. 


Injuries  to  the  Pelvic  Organs  Caused  by  the  Improper  Use  of 
Pessaries. — The  dangers  of  stem  pessaries  have  ah'eady  beeu  referred 
to  in  the  chapter  on  flexions,  so  far  as  their  hability  to  cause  acute 
inflammations  of  the  uterus,  pelvic  ceUular  tissue,  and  peritonaeum. 
There  are  still  other  injuries  whicli  they  may  give  rise  to.  When 
the  stem  is  small  and  badly  adjusted  with  reference  to  the  character 
of  the  flexion,  the  point  of  the  instrument  may  become  imbedded  in 
the  wall  of  the  uterus,  or  the  lower  part  of  the  stem  may  divide  the 
posterior  wall  of  the  cervix.  Both  of  these  injuries  I  have  seen  in 
practice. 

In  one  case,  an  anteflexion  of  the  cervix,  a  small  stem  of  steel  with 
a  hard-rul)ber  disk  at  its  end  was  introduced  by  a  general  practi- 
tioner, and  left  in  place  for  three  months. 
The  patient  soon  began  to  suffer  from  a 
inirulent  discharge,  which  gradually  in- 
creased, and  there  was  much  pain,  greatly 
aggravated  by  walking.  AVhcn  I  saw  her 
the  relations  of  the  stem  and  uterus  were 
as  shown  in  Fig.  161.  After  the  removal 
of  the  stem,  the  cervix  presented  exactly 
the  same  appearance  as  that  seen  after 
Sims's  operation  for  flexion,  except  that 
there  was  more  thickening  of  the  edges  of 
the  wound  and  more  inflammation  than  I 
have  ever  before  seen  after  discision  of  tlie 
cervix  by  the  surgeon.  The  inflammation 
subsided  under  ordinary  treatment,  and  she 
was  at  least  none  the  worse  for  having  worn  the  stem. 

Another  patient  came  under  iny  observation  while  wearing  a  stem 
pessary,  which  had  been  introduced  six  weeks  before  by  her  medical 


Fig.  161. — Stem  of  pessary  ul 
ccratinff  through  cervix. 


ABUSE   OF   PESSARIES. 


}35 


attendant.  She  had  suffered  pain  and  tenderness  from  the  time  that 
the  stem  was  introduced,  and  for  a  week  before  she  came  under  my 
care  the  suifering  was  so  great  that  she  was  obliged  to  stay  in  bed 
and  take  opium  freely ;  she  had  also  a  purulent  discharge,  and  at 
times  bleeding.  The  stem  was  about  the  thickness  of  a  No.  9 
catheter.  It  was  made  of  hard  rubber,  and  was  held  in  place  by  a 
cup  pessary  in  the  vagina.  While  the  stem  was  still  in  place  (the 
vaginal  pessary  having  been  removed)  the  body  of  the  uterus  was 
found  to  be  markedly  anteflexed,  and  its  anterior  wall  near  the 
fundus  was  unusually  prominent,  as  if  it  contained  a  small  fibroid 
tumor. 

The  Hexed  shape  of  the  uterus  led  me  to  suppose  that  the  stem 
must  be  curved,  but  on  removal  it  proved  to  be  straight. 

I  then  passed  with  some  difficulty,  owing  to  the  tenderness  of 
the  uterus,  a  much-curved  sound  into  the  cavity  of  the  uterus,  and 
then  after  straightening  the  sound,  it  was  passed  into  the  groove 
made  in  the  posterior  wall  by  the  stem.  One  might  suj^pose  that 
the  cavity  of  the  uterus  was  simply  dilated 
so  that  the  sound  could  be  curved  forward 
and  then  straightened  and  passed  along  the 
posterior  wall,  but  I  am  confident  that  such 
was  not  the  case.  The  posterior  wall  of  the 
body  was  flexed  forward  and  rested  upon 
the  anterior  wall  on  either  side,  and  the  sul- 
cus made,  by  the  stem  was  in  the  center. 

Fig.  162  shows  the  conditions  as  they  ap- 
peared to  me  during  my  examination. 

There  was  considerable  bleeding  after 
the  removal  of  the  stem,  and  the  uterus  be- 
came more  flexed  apparently  as  soon  as  the 
support  was  withdrawn.  There  was  relief 
from  the  acute  symptoms  and  inflammation  caused  by  the  instru- 
ment, but  the  dysmenorrhoea  was  worse  than  before. 

Atropliy  of  the  muscular  tissue  of  the  vaginal  walls  from  over- 
distention  by  pessaries  that  are  too  large  is  quite  frequently  seen. 
Practitioners  who  are  not  skilled  in  the  use  of  pessaries,  yet  never- 
theless use  them,  produce  this  injury  of  the  structures  of  the  vagina. 
The  same  unfortunate  results  are  effected  by  those  who  believe  in 
the  theory  that  in  order  to  keep  the  uterus  in  place,  in  retroversion, 
for  example,  it  is  necessary  to  use  a  pessary  large  enough  and  suf- 
ficiently curved  to  force  the  posterior  wall  of  the  vagina  far  up  in 
the  pelvis  above  its  normal  elevation. 


Fig.  162.— Stem   cutting- 
through  body  of  uterus. 


336 


DISEASES   OF   WOMEN. 


The  followinf]^  case  will  illustrate  this :  The  ])atient  had  children, 
and  wiuj  said  to  have  had  a  displacement ;  jjrubably  n  troversion. 
She  was  treated  with  a  variety  of  pessaries,  so  she  told  me,  but  did 
not  get  well  ;  when  she  came  to  me,  she  had  much  backache,  ])elvic 
pain,  and  vaginal  leucorrlui'a ;  she  was  then  wearing  a  pessary  nearly 
large  enough  to  fill  the  pelvis,  and  much  curved  both  in  front  and 
behind. 

The  uterus  was  in  about  its  proper  place  in  the  pelvis,  but  the 
vagina  was  greatly  overdistended  and  its  walls  were  thin,  especiall\ 
the  posterior  wall  behind  the  cervix.     On  removing  the  pessary,  a 

difficult  task  owing  to  its 
size,  the  vaginal  wall,  and 
the  rectal  wall  also,  I  think, 
fell  downward  and  f(jrmed 
a  rectocele  high  up. 

Fig.  163  will  give  an 
idea  of  the  state  of  the  parts 
as  they  appeared  to  the 
touch,  after  the  pessary  was 
removed. 

The  part  of  the  thin  wall 
of  the  vagina  bulijed  down- 
ward,  and  felt  to  the  touch 
exactly  like  the  ordinary 
rectocele,  except  that  the 
protniding  mass  was  at  the 
upper  part  of  the  vagina  in- 
stead of  the  lower ;  when  seen  through  the  speculum  introduced 
about  an  inch  and  a  half,  this  was  confirmed  by  the  eye. 

The  first  impression  obtained  by  the  touch  was  that  of  a  portion 
of  intestine  distended  with  gas  lying  behind  and  below  the  cervix 
uteri.  The  patient  felt  a  little  more  distress,  strange  to  say,  after 
the  pessary  was  removed  ;  when  slie  tried  to  walk  without  it,  she 
suffered  from  pain  and  tenesmus  very  severely.  This  I  have  found 
to  be  the  case  in  all  instances  of  overdistention  of  the  vagina; 
patients  suffer  with  tlie  support,  and  for  a  few  days  suffer  more 
without  it. 

This  is  much  the  same  experience  as  ladies  have  who  can  not  go 
without  corsets,  and  the  tighter  they  lace  them  and  the  more  damage 
they  do,  the  more  they  miss  them  when  they  discontinue  their  use. 
This  patient  was  kept  rather  quiet  for  a  time,  and  astringent  in- 
jections were  used,  which,  after  a  long  time,  restored  the  vagina  more 


-High  rectocele  due  to  improper  pes- 
sary. 


ABUSE  OF  PESSARIES.  337 

nearly  to  its  normal  caliber.  There  remained  for  over  a  year,  when 
I  last  saw  her,  and  perhaps  ever  since,  a  sagging  of  the  upper  part 
of  the  posterior  vaginal  wall. 

Another  case,  somewhat  of  the  same  character,  came  to  me  from 
the  West.  She  was  forty,  and  single  ;  her  health  and  strength  had 
been  good  until  she  was  thirty-six  years  of  age,  when  she  began  to 
have  a  variety  of  nervous  symptoms  clearly  due  to  general  debility. 
She  was  treated  by  several  reputable  physicians,  but  not  recovering 
as  fast  as  she  desired,  she  consulted  still  another,  who  told  her  that 
she  had  falling  of  the  womb,  which  caused  all  her  troubles.  There 
was  not  a  symptom  that  pointed  to  any  disease  or  displacement  of 
the  sexual  organs,  but  a  Cutter  pessary  was  introduced  and  the 
patient  wore  it  about  two  years.  Her  general  health  improved  very 
little,  and  the  pessary  soon  caused  her  trouble ;  still  she  persisted  in 
wearing  it  because  the  doctor  said  she  must  do  so ;  her  condition  be- 
came so  wretched  that  she  came  East,  in  the  hope  of  gaining  relief. 

When  she  came  to  me  she  had  some  vaginitis  and  vulvitis 
caused  by  the  pessary,  but  the  uterus  was  perfectly  normal  in  every 
way.  The  Cutter  pessary  had  pushed  up  the  posterior  vaginal  wall 
fai-  beyond  the  cervix,  which  lay  on  one  side  of  the  instrument,  i:iot 
between  the  bars  as  it  should  have  done. 

The  condition  of  the  posterior  vaginal  wall  at  the  upper  part  was 
about  the  same  as  in  the  case  just  related.  The  lower  part  of  the 
vagina  was  normal,  excepting  the  inflammation  caused  by  the  pes- 
sary. The  vulva  was  also  inflamed,  and  she  sufl'ered  greatly  from 
this,  especially  in  taking  exercise.  This  patient  also  felt  the  want  of 
the  pessary  when  it  was  removed,  but  only  for  a  short  time.  She 
was  examined  seven  months  after  the  removal  of  the  instrument  and 
was  found  to  be  perfectly  well. 

Injury  of  the  Posterior  Vaginal  Wall  by  the  use  of  Pessaries  in 
Cases  of  Incurable  Retroversion. — This  case  illustrates  a  class  which, 
thouffh  not  larffe,  deserves  notice.  In  retroversion  with  fixation  of 
the  uterus,  either  from  a  cono;enital  state  or  because  of  adhesions  or 
shortening  of  the  post-uterine  ligaments,  there  is  sometimes  a  slight 
mobility  of  the  uterus  which  admits  of  its  being  partly  restored. 
This  leads  the  practitioner  to  hope  that,  by  the  use  of  the  pessary, 
the  displacement  can  be  corrected.  The  result  is  that  the  posterior 
portion  of  the  pessary  makes  too  great  pressure  upon  the  vaginal 
wall  and  produces  inflammation  and  abrasion.  This  usually  causes 
a  free  vaginal  discharge  and  pain  enough  to  make  the  patient  seek 
relief  before  much  permanent  injury  is  done.  In  all  such  cases  pes- 
saries should  not  be  used  at  all,  but  if  one  is  employed  in  the  hope 
23 


338  DISEASES   OF   WOMEN. 

of  doing  good,  it  should  be  abandoned  as  soon  as  it  causes  anv  irri- 
tation. 

In  these  incurable  cases,  a  slight  relief  may  sometimes  be  given 
by  using  a  Peaslee's  ring,  or  a  Smith's  pcfssary  very  little  if  at  all 
curved  posteriorly.  Either  of  these  instruments  will  hold  the  uterus 
a  tritle  higher  in  the  pelvis,  and  this  will,  in  some  cases,  give  a  sense 
of  su}>j»<'rt  and  relief  To  tlie  ])atient. 

Overdistention  and  Atrophy  of  the  Anterior  Vaginal  Wall  from 
the  use  of  Anteversion  Pessaries. — This  condition  is  rarely  seen  ex- 
cept among  the  patients  of  those  who  look  upon  anteversion  as  a 
morbid  state  of  importance  whenever  it  occurs. 

In  order  to  raise  the  body  of  tlie  uterus  up  when  it  is  anteverted, 
it  is  necessary  to  elevate  the  anterior  vaginal  wall  far  beyond  its 
normal  position.  In  order  to  do  this,  the  instrument  must  make 
well-marked  pressure  upon  the  parts,  and,  if  this  is  continued,  the 
muscular  wall  becomes  atrophied  and  overdistended,  and  this  can 
be  carried  on  to  a  very  great  degree,  the  whole  length  of  the  vagi- 
nal wall  becoming  double  that  which  it  originally  was. 

"When  the  pessary  is  removed  in  such  a  condition,  there  is  at 
once  observed  a  well-defined  and  large  prolapsus  of  the  vaginal  wall, 
and  if  the  instrument  is  left  out,  cystocele  will  soon  follow.  This 
is  the  rule,  but  the  final  results  depend  to  some  extent  upon  the 
length  of  time  that  the  pessary  has  been  worn. 

The  stretching  of  the  vaginal  walls  caused  by  pessaries  can  Ix* 
overcome  by  removing  the  instrument,  and  prescribing  rest  and 
astringent  injections.  But  if  the  overdistention  has  been  kept  up 
long  enough  to  cause  atrophy  of  the  muscular  tissue,  the  injury  is 
permanent  and  can  be  very  little  improved  by  treatment. 

There  is  also  danerer  to  the  bladder  and  urethra  from  the  ante- 
version  pessary.    The  following  case  will  show  how  this  comes  about : 

Frequent  "Urination  associated  with  Slight  Anteversion  of  the  Blad- 
der.— The  lady  was  about  thiity.  and  had  a  child  seven  years  old. 
Slie  gradually  developed  a  pelvic  tenesmus  and  some  irritability  of 
the  bladder.  She  consulted  her  physician,  who  diagnosticated  ante- 
version of  the  uterus,  and  stated  that  the  disturbed  function  of  the 
bladder  was  due  to  the  malposition  of  the  uterus.  Thomas's  ante- 
version pessary  was  introduced  by  the  physician  in  charge  ;  this 
gave  the  patient  a  sense  of  support  which  was  agreeable,  but  more 
disturbance  of  the  bladder  was  caused.  The  physician  urged  the 
patient  to  wear  the  pessary,  telling  her  that  she  would  get  used  to 
it,  and  the  unfavorable  effects  would  pass  off  ;  but  this  proved  not 
to  be  the  fact.     The  patient  then  came  under  my  care,  having  woni 


ABUSE   OF  PESSARIES. 


J39 


the  pessary  for  two  weeks ;  I  at  once  removed  it,  witli  the  result  of 
giving  some  relief,  but  there  was  still  more  impatience  of  the  blad- 
der than  before  the  instrument  was  used  at  all.  The  tnie  state  of 
affairs  proved  to  be  that  the  patient  had  a  slight  catarrh  at  the  neck 
of  the  bladder,  not  due  to  the  malposition  of  tlie  uterus  at  all,  and 
the  pessary  only  increased  the  original  affection. 

In  proof  of  this,  the  symptoms  all  disappeared  when  the  disease 
of  the  bladder  was  removed,  and  without  changing  the  position  of 
the  uterus  in  the  least. 

Cup  Pessary  with  an  Extra-Vaginal  Support,  causing  Vulvitis  and 
Ulceration  of  the  Vagina. — All  the  pessaries  having  a  stem  attached 
to  a  band  around  the  body  have  given  trouble  when  worn  for  any 
length  of  time.  The  evil  caused  by  the  one  used  in  this  case,  is 
typical  of  most  of  them. 

The  patient  lived  in  the  country,  and,  while  suffering  from  pel- 
vic tenesmus,  called  in  a  physician  who  adjusted  a  Babcock's  uterine 
supporter  for  "  falling  of  the  womb."  She  was  directed  to  remove 
it  at  night  and  introduce  it 
in  tlie  morning.  For  a  short 
time  she  felt  some  relief, 
but  soon  began  to  suffer 
from  a  profuse  vaginal  dis- 
charge and  great  tenderness 
about  the  vulva.  The  suf- 
fering increased  until  she 
was  unable  to  walk,  and  the 
introduction  of  the  support- 
er gave  great  pain. 

When  I  examined  her  I 
found  the  relations  of  the 
uterus  and  supporter  as  rep- 
resented in  Fig.  164.  The 
uterus  was  retroverted  and 
the  cup  and  stem  were  situ- 
ated in  front  of  the  cervix 
and  held  the  anterior  vaginal  wall  high  above  its  normal  position. 
There  was  some  ulceration  of  the  vaginal  wall  and  general  vaginitis 
and  vulvitis. 

The  apparatus  was  removed,  vaginal  injections  of  borax  and 
water  employed,  and  in  a  short  time  the  inflammation  was  relieved. 
The  uterus  was  then  restored  to  its  normal  position,  and  retained 
there  with  a  pessary  such  as  I  u6e  in  such  cases,  and  she  did  very 


Fig.  164. — Displacement  caused  by  a  badly  adjusted 
pessary. 


340  DISEASES  OF   WOMEN. 

well.  But  for  several  inoiitlis  there  was  a  tendency  to  prolapsus 
of  the  anterior  vaginal  wall,  owing  to  the  overstretching  oi  it  In 
her  former  sui)])orter. 

The  Upper  Rim  of  a  Cup  Pessary  partially  imbedded  in  the  Vagina, 
around  the  Cervix  Uteri. — 'I'his  ])atient  had  a  prulap.sii>  uteri,  and 
the  physician  who  had  her  in  care  used  a  cup  and  stem  of  soft  rub- 
ber ;  the  cup  was  quite  a  large  one  and  its  edges  were  rather  sharp. 
I  think  it  was  called  the  liarrington  supporter.  She  was  much  re- 
lieved by  this  instrument,  being  aljle  to  do  her  duty  as  a  laundress, 
but  she  began  to  have  a  vaginal  discharge  and  occassional  bleeding, 
with  pain  and  tenderness.  I  saw  her  with  the  doctor  and  found  a 
ring  of  raw  tissue  in  the  vagina,  around  the  cervix  uteri,  correspond- 
ing to  the  size  and  shape  of  the  cup. 

The  uterus  was  large,  measuring  nearly  five  inches.  Evidently 
the  pressure  uijon  the  instrument  was  more  than  the  tissues  of  the 
vagina  could  stand.  The  patient  rested  for  a  time  and  used  vagi- 
nal injections ;  the  parts  healed  promptly,  but  the  scar  tissue  re- 
mained tender,  and  gave  way  under  the  pressure  of  the  insti-ument, 
whenever  she  wore  it  for  anj  length  of  time. 

I  think  that  this  patient  could  have  been  cured  by  rest  in  the 
recumbent  position  until  the  enlargement  of  the  uterus  and  relax- 
ation of  the  vagina  had  been  overcome,  and  then  the  pehnic  lioor 
restored.  But  she  could  not  give  the  time  to  this,  being  poor,  and 
obliged  to  work  to  live.  She  was  directed  to  wear  a  perineal  pad 
fastened  to  a  wai.st-l)elt,  and  she  got  along  fairly  well  in  that  way. 

A  Pessary  imbedded  in  the  Posterior  Vaginal  Wall. — In  the  cur- 
rent literature  there  have  been  many  extraordinary  cases  recorded  of 
pessaries  having  passed  through  the  vaginal  walls  into  the  rectum 
and  bladder.  Some  of  these  cases  have  been  very  remarkable,  and 
have  been  recorded  as  matters  of  curiosity.  Little  has  been  said 
about  the  causes  of  such  accidents  or  how  to  manage  them. 

The  following  case  illustrates  the  most  common  forms  of  this  ac- 
cident :  The  patient  was  a  widow  who  had  borne  several  children, 
and  had  been  well  until  the  menopause,  vchen  she  became  insane. 
At  the  outset  of  her  mental  derangement,  her  physician  suspected 
that  she  had  some  uterine  disease,  and,  on  investigating  the  case, 
found  the  uterus  larger  than  it  ought  to  be  and  rctroverted.  H( 
restored  the  organ  to  its  normal  position  and  introduced  a  pessarv 
which  held  it  there ;  the  instrument  was  well  adapted  and  answered 
the  purpose  well.  After  this  his  attention  was  wholly  directed  h 
her  mental  condition,  and  she  recovered  her  mind  in  about  one  year. 
The  pessary  was  forgotten  by  her   physician,  who    introduced  il 


ABUSE  OF  PESSARIES.  341 

while  she  was  in  the  asylum.  When  she  came  home,  or  soon  after, 
she  began  to  have  a  discharge  from  the  vagina  and  occasional  bleed- 
ing. I  then  was  called  to  examine  her,  and  found  all  that  portion 
of  the  pessary  which  rested  behind  the  cervix  uteri,  iudjedded  in  the 
vaginal  wall.  The  tissues  to  the  extent  of  nearly  a  (juarter  of  an 
inch  had  united  in  front  of  the  pessary  bar. 

Traction  was  made  upon  the  pessary  until  the  tissues  inclosing  it 
were  made  tense,  and  they  were  then  divided  down  to  the  instru- 
ment ;  there  was  much  bleeding,  but  the  parts  healed  well,  leaving  a 
large  scar  in  the  posterior  vaginal  wall. 

This  case  is  one  the  like  of  which  is  not  infrequently  seen ;  they 
differ  from  most  of  those  already  mentioned,  in  the  important  fact 
that  tliey  occur  in  cases  in  which  the  instrument  is  well  adjusted  and 
answers  its  purpose  for  a  time,  causing  no  trouble  until  the  vagina 
begins  to  contract  during  the  final  involution  at  the  menopause. 

The  vagina  contracts  so  much  that  the  pessary,  which,  at  the 
time  of  its  introduction  was  small  enough  and  had  plenty  of  room, 
becomes  altogether  too  large  and  must  imbed  itself  in  the  vaginal 
walls.  I  have  seen  a  sufficient  number  of  these  cases  to  satisfy  my- 
self that  they  occur  in  the  practice  of  the  most  competent  gyne- 
cologists, sometimes,  perhaps,  from  neglect  in  giving  specific  direc- 
tions to  the  patient  to  report  from  time  to  time,  so  that  the  behavior 
of  the  pessary  may  be  watched,  but  more  often  from  the  fact  that 
the  patient  having  been  relieved  of  all  her  symptoms,  either  forgets 
the  pessary,  or  else  feels  secure  and  safe,  so  long  as  there  is  no  suf- 
fering which  she  can  not,  in  her  own  opinion,  attribute  to  tbe  meno- 
pause, the  time  when  there  is  the  greatest  danger  of  the  accident  in 
question. 

Pessary  entirely  imbedded  in  the  Vaginal  Walls,  except  about 
three  quarters  of  an  inch. — This  patient  came  to  me  v/hen  she  was 
forty-six  years  old ;  she  vv^as  still  menstruating,  but  irregularly,  and 
on  one  or  more  occasions  had  menorrhagia.  She  was  suffering  from 
a  prolapsus  of  the  uterus  which  caused  her  much  trouble  when  she 
was  on  her  feet.  I  restored  the  uterus,  and  used  an  instrument  to 
keep  it  in  place.  This  gave  her  relief  at  once,  and  she  was  able  to 
take  up  her  duties  as  in  times  past.  She  came  to  see  me  several 
times  and  I  made  some  applications  to  the  uterus  which  caused  a 
slight  endometritis.  I  directed  ber  to  continue  her  visits  from  time 
to  time,  in  order  that  I  might  see  how  the  pessary  was  acting  ;  this 
she  did  not  do,  for  feeling  perfectly'  well,  she  concluded  that  there 
was  no  need  of  further  treatment,  and  she  acted  accordingly.  Ten 
years  passed,  and  though  she  began  to  have  a  purulent  discharge 


342  DISEASES  OF  WOMEN. 

and  occasional  bleedin^  from  the  vagina,  still  she  neglected  hep. 
self.  After  a  time  she  eulied  a  physician,  who  made  a  suj>erticial 
examination,  and  told  her  that  he  suspected  that  she  might  have  cait 
cer;  he  advised  her  to  place  herself  again  under  my  care;  this  she 
did,  and  1  found  the  vagina  almost  completely  closed.  On  tbo 
right  side  anteriorly,  I  found  a  small  portion  of  the  pessary  exposed, 
but  the  rest  was  imbedded  in  the  vaginal  walls  and  covered  over 
by  considerable  tissue. 

The  granular  and  highly- vascular  character  of  the  tissues  sug- 
gested that  the  doctors  suspicion  of  cancer  might  be  correct.  The 
pessary  could  be  felt  through  the  wall  of  the  rectum  which  appeared 
to  be  quite  thin  at  that  point. 

Passing  a  sound  into  the  Ijladder,  a  part  of  the  pessary  appeared 
to  be  encroaching  uj)on  it.  With  difficulty  the  finger  could  be  passed 
between  the  free  portion  of  the  pessary  and  the  vaginal  wall  until 
it  reached  the  cervix  uteri,  which  was  normal.  The  pessary  had  to 
be  removed,  yet  the  task  appeared  to  be  a  difficult  one.  There  was 
so  much  haemorrhage  caused  by  the  examination  that  I  dared  not 
divide  the  tissues  which  enclosed  the  pessary,  neither  did  I  feel  that 
I  could  with  safety  rapidly  and  forcibly  tear  the  instrument  out  of 
its  place,  fearing  that  I  might  do  damage  to  the  rectum  and  blad- 
der. I  finally  adopted  the  following  method  with  success :  Using  a 
Sims's  speculum,  I  seized  the  part  that  was  exposed  in  the  anterior 
part  of  the  vagina  with  a  very  strong  forceps,  and  ^^"ith  a  small 
finger-saw  cut  out  the  section  within  reach.  I  then  laid  hold  of  an 
end  and  by  traction  caused  the  pessary  to  revolve  until  another  por- 
tion came  into  the  place  of  the  one  removed ;  this  was  sawed  off, 
and  piece  after  piece  was  taken  out  in  this  way  until  the  whole  was 
removed. 

The  sinus  was  washed  out  for  the  j^urpose  of  cleaning  it  and 
stopping  hfemorrhage,  but  there  was  so  nmch  bleeding  that  1  had  to 
use  a  tampon  to  control  it. 

The  patient  did  quite  well,  and  beyond  a  marked  thickening  of 
the  vaginal  walls,  has  now  no  trace  of  the  injury. 

Since  my  experience  with  this  case,  I  have  seen  quite  a  number 
of  cases  of  imbedded  pessaries,  and  have  removed  them  in  the  way 
described.  Two  cases  I  have  in  mind  now  in  which  the  pessaries 
were  imbedded  in  the  posterior  vaginal  wall,  were  treated  by  sawing 
out  the  anterior  half  or  third  of  the  pessary,  and  then  by  turning 
the  remaining  portion  around  it  was  destroyed  and  removed  without 
breaking  down  or  dividing  the  tissues  surrounding  it. 


CHAPTER   XX. 

HYPERTROPHY    OF    THE    CERVIX    UTERI. 

This  is  a  peculiar  and  rather  rare  affection.  It  differs  from  the 
enlargement  of  the  entire  nterus,  which  occurs  in  pregnancy  and  in 
some  of  the  inflammatory  affections.  The  hypertrophy  is  confined 
to  the  vaginal  portion  of  the  cervix,  and  is  distinct  from  the  enlarge- 
ment of  the  supra-vaginal  portion,  which  occurs  in  connection  with 
metritis,  subinvolution,  and  pregnancy. 

Pathology. — The  only  change  in  structure  of  the  cervix  is  in 
quantity.  The  length  of  the  cervix  is  increased,  which  is  the  main 
point  in  -the  pathology.  Sometimes  it  is  thickened,  but  not  in  pro- 
portion to  the  elongation.  It  is  characterized  by  great  increase  in 
length  without  increase  in  the  diameter  of  the  cervix,  and  no 
changes  occur  in  the  composition  of  the  tissues.  This  is  a  true 
hypertrophy,  which  occurs  from  causes  wholly  different  from  the 
ordinary  conditions  which  produce  hypertrophy.  The  extent  of 
hypertrophy  differs  in  different  cases  ;  this  is  due,  to  some  extent, 
to  the  stage  of  progress  when  the  first  examination  is  made.  In 
some  cases  the  cervix  projects  from  the  vulva  one  or  more  inches, 
while  in  others  the  cervix  rests  just  behind  the  hymen  or  in  the 
vulva  (Fig.  165). 

The  cervix  is  generally  conical  and  the  os  externum  is  generally 
small,  as  it  should  be  in  the  virgin  cervix. 

It  occurs  in  the  unmarried  most  frequently,  but  occasionally  in 
those'  who  are  married  but  sterile. 

Symptomatology. — The  symptoms  are  exactly  the  same  as  those 
due  to  prolapsus.  In  the  first  stage  there  is  pelvic  tenesmus,  and  a 
sense  of  overdistention  of  the  vagina.  The  presence  of  this  large 
cervix  causes  irritation  of  the  vagina  and  consequent  leucorrhoea. 
Owing  to  the  great  increase  in  the  length  of  the  uterus,  it  becomes 
doubled  up  in  the  pelvis,  and  this  often  affects  the  menstrual  func- 
tion, giving  rise  to  dysmenorrhoea.     In  the  last  stage  of  the  affec- 


I 


344 


DISEASES   OF   WOMEN. 


tion,  in  which  the  cervix  protrudes  from  the  vulva,  there  is  much 
discomfort ;  and  the  feehng  of  distention  causes  great  irritabihtj  of 


Fig.  165. — Hypertrophy  of  the  cervix.    {^.) 

the  general  nervous  system.     Excoriations  and  ulcerations  of  the 
mucous  membrane  are  produced. 

Pliysical  Signs. — The  bimanual  touch  reveals  the  fact  that 
while  the  fundus  uteri  is  at  its  normal  elevation,  the  cervix  is  either 
down  at  the  vulva  or  protruding  beyond  it.  At  the  same  time  the 
firmness  of  the  vaginal  walls,  occupying  their  normal  position,  shows 
the  great  length  of  the  extra-vaginal  part  of  the  cervix.  This  sign 
is  diagnostic  when  the  cervix  is  still  within  the  vulva,  but  when  the 
cervix  has  escaped  through  the  vulva  there  is  prolapsus  of  the  vagina 
which  obscures  the  signs  to  some  extent.  Emmet  claims  that  elon- 
gation from  prolapsus  of  the  uterus  has  been  mistaken  for  hyper- 
trophic elongation.  This  does  not  seem  possible  for  one  who  knows 
anything  about  the  nidiments  of  gynecology.  By  restoring  the  pro- 
lapsed uterus,  any  little  elongation  M-liich  may  have  come  from 
stretching  will  disappear,  while  no  change  of  position  will  make  any 
difference  of  length  in  hypertrophy.     The  use  of  the  sound  also 


HYPERTROPHY    OF   THE   CERVIX   UTERI. 


345 


helps  greatly  in  determining  the  extent  of  the  hypertrophic  elon- 
gation. 

Causation. — The  fact  that  this  affection  is  limited  to  the  virgin 
cervix  makes  it  appear  as  if  the  hypertrophy  might  be  due  to  neg- 
lected functions,  but  the  fact  is  that  its  cause  is  not  known. 

Prognosis. — The  hyj)ertrophy  yields  to  surgical  treatment  very 
promptly.  All  the 
cases  that  I  have 
treated,  five  altogeth- 
er, have  been  com- 
pletely relieved  by 
amputation  of  the 
cervix. 

Treatment. — The 
removal  of  the  super- 
abundant intra-vagi- 
nal  portion  of  the 
cervix  by  amputa- 
tion, is  the  only  meth- 
od of  treatment  which 
gives  satisfaction. 

Several  methods 
of    operating     have 

been  employed,  such  as  the  circular  method,  made  with  the  knife  or 
scissors,  the  ecraseur,  and  the  galvano-cautery  wire.  Originally,  in 
all  of  these  methods  the  stump 
was  left  to  heal  by  granula- 
tion. J.  Marion  Sims  greatly 
improved  the  operation  by 
covering  the  stump  with  mu- 
cous membrane.  Simon  and 
Marckwald  made  a  double- 
flap  operation,  and  I  have 
adopted  a  modification  of  this 
method.  The  details  of  the 
operation,  as  I  perform  it,  are  Fig.  \ 
as  follows : 
A  rubber  cord  is  passed  around  the  cervix  and 
drawn  tight  enough  to  control  the  hgemorrhage ;  the  ends  of  this 
cord  are  then  seized  with  a  fixation- forceps,  which  keeps  them 
from  slipping,  and  also  holds  the  cervix  in  the  desired  position. 
The  cervix  is  divided  from  the  canal  outward  on  either  side  as 


Fig.  166. — The  first  step;  splitting  the  cervix. 


Fig. 


167.—The  double  flaps 
of  the  amputation. 


.  —  Dia- 
gram of  the 
pieces  removed. 


346 


DISEASES   OF    WOMEN. 


high  up  as  the  amputation  is  to  be  made  (Fig.  106).     The  double 
flaps  are  then  made  with  the  scalpel  in  such  a  way  that  the  two 

short  flaps  are  on  the  in- 
side (I'igs.  167  and  168). 
The  portions  removed  are 
wedge-shaped. 

Two  middle  sutures 
are  then  introduced  from 
the  cervical  mucous  mem- 
brane, or  short  flaps,  to 
the  outer  mucous  mem- 
brane, and  the  lateral  sut- 
ures are  used  in  the  same 
way  as  in  restoring  a  bilat- 
eral laceration.  Fig.  169 
sbows  the  sutures  a.s  intro- 
duced, and  Fig.  170  shows 
them  when  tied. 

Before  tying  the  sut- 
ures tlie  rubber  cord 
should  be  loosened,  and  if 
there  are  any  vessels  that 
bleed  freely  they  should 
be  controlled.  Slight  ooz- 
ing is  controlled  complete- 
ly by  tying  the  sutures. 
There  are  two  things  M'hich  have  been  brought  out  by  experi- 
ence, and  these  should  be  kept  in  mind.  The  tirst  is,  that  the  cer- 
vix after  amputation  retracts  or  shrinks, 
so  til  at  it  should  not  be  amputated  too 
high  up,  but  left  a  quarter  or  three 
eighths  of  an  inch  longer  than  it  should 
apparently  be.  It  will  he  found  short 
enough  two  or  three  months  after  the  op- 
eration. The  next  point  is,  that  the 
middle  and  outer  layers  retract  after  the 
operation  far  more  than  the  mucous 
membrane  of  the  cervix  ;  especially  is 
this  the  case  when  there  is  a  cervical 
endometritis  present.     In  several  of  my 

cases,  I  found  several  months  after  the  operation  that  the  mucous 
membrane  protruded  from  the  os  externum,  and  had  to  be  clij)ped 


Fig.  169. — The  sutures  in  place. 


Fig.  170. — The  sutures  tied. 


HYPERTROPHY   OF  THE   CERVIX   UTERI.  347 

oflF.  This  is  a  simj)le  thing  to  do,  Imt  by  observing  the  directions 
this  item  of  after-treatment  will  not  be  recj^uired. 

The  after-treatment  is  the  same  as  that  employed  in  the  op- 
eration for  restoring  a  lacerated  cervix  uteri,  and  need  not  be  de- 
scribed here. 

In  a  certain  number  of  cases  I  have  noticed  that  the  outer  walls 
of  the  cervix  retract  more  than  the  mucous  membrane  after  this 
operation.  Immediately  after  the  parts  have  healed,  the  cervix  is 
quite  perfect,  but  in  a  few  months  the  mucous  membrane  protrudes 
beyond  the  muscular  wall.  This  is  more  likely  to  occur,  I  think, 
in  case  there  is  a  cervical  endometritis  accompanying  the  hyper- 
trophic elongation.  When  this  condition  of  protrusion  or  prolapsus 
of  the  cervical  nmcous  membrane  is  found  subsequent  to  amputa- 
tion, the  easiest  and  quickest  way  is  to  draw  the  superabundant  tis- 
sue and  clip  it  off. 

Just  here  I  may  mention  that  hypertrophic  elongation  of  the 
anterior  half  of  the  cervix  occasionally  occurs  in  bilateral  laceration. 
When  this  elongation  is  very  great,  I  have  found  it  best  to  amputate 
the  redundant  part  as  a  preliminary  to  the  operation  for  the  lacera- 
tion. This  is  done  in  the  same  way  as  taking  off  a  finger  by  the 
flap  operation. 


CHAPTER   XXL 

riBEOMA    OF    THE   UTERUS. 

These  new  growths  of  the  uterus  belong  to  the  middle  period  of 
life,  occurring  during  functional  activity  of  the  uterus,  and  are  the 
most  benign,  both  in  composition  and  behavioi-,  of  all  the  neoplasms 
of  the  uterus.  They  partake  far  more  of  the  nature  of  a  hyper- 
plasia than  a  degeneration.  Fibromata  originate  in  the  middle  coat 
of  the  uterus  and  in  histological  composition  are  the  same  as  the 
tissues  which  produce  them.  Efforts  have  been  made  to  lind  some 
difference  between  the  structure  of  these  growths  and  that  of  the 
wall  of  the  uterus,  and  several  names  have  been  employed  whicli 
would  convey  some  idea  of  their  structure.  Filjroid,  fibrous  myoma, 
fibro-myoma,  and  hysteroma  are  the  names  that  have  been  used  to 
designate  these  tumors.  I  prefer  the  term  fibroma,  believing  that  it 
is  as  comprehensive  and  indicative  of  the  chai'acter  of  the  growth  as 
any.  By  comparing  a  section  of  the  uterine  wall  with  a  section  of 
fibroma,  it  will  at  once  appear  that  they  are  very  much  alike.  Both 
are  composed  of  muscular  fibro-cells,  fibro-plastic  elements,  and  cellu- 
lar tissue.  There  is  also  a  similitude  in  their  function  or,  more  prop- 
erly speaking,  both  the  tissues  of  the  middle  coat  of  the  uterus  and 
those  composing  a  fibroma  are  similar  in  their  behavior  in  this  re- 
spect ;  they  are  both  given  to  great  increase  by  growth  and  decrease 
by  atrophy. 

While  it  is  a  fact  that  the  same  histological  elements  are  found 
in  the  wall  of  the  uterus  and  in  fibromata,  the  construction  and  ar- 
rangement of  these  tissues  differ  sufficiently  to  cause  a  difference  in 
the  physical  characters  of  the  two.  Compared  with  the  wall  of  the 
uterus  the  fibroma  is  more  pearly  white  in  color,  less  vascular,  usual- 
ly more  dense  to  the  touch,  and  cuts  more  like  cartilage. 

Fibromata  grow  usually  in  the  body  and  fundus  of  the  uterus, 
but  in  rare  cases  they  have  been  found  in  the  cervix.  All  of  these 
growths  nmst  of  necessity  begin  in  the  muscular  tissue  of  the  wall  of 


FIBROMA   OF   THE   UTERUS. 


349 


Fig  171.  Fin.  172. 

Figs.  171,  172. — Interstitial  fibro- 
mata (Winckel). 


the  uterus,  but  the  direction  in  which  they  grow  varies  in  different 
cases,  and  this  has  led  to  a  very  clear  and  useful  classiiication  of 
fibromata.  When  the  tumor  remains  im- 
bedded in  the  middle  coat  of  the  wall  of 
the  uterus  it  is  called  interstitial  (Figs. 
171  and  172),  when  it  grows  toward  the 
outside,  subperitoneal,  and  when  it  grows 
toward  the  cavity  of  the  uterus,  submu- 
cous. Figs.  171  to  173  will  show  the 
three  forms  classed  according  to  location. 
The  subperitoneal  variety  might  well  be 
divided  into  two  classes,  those  that  are 
situated  outside  of  the  broad  ligament 
and  those  that  are  within  its  folds. 

Though  very  little  has  been  said  in  books  about  the  fibromata 
which  grow  within  the  folds  of  the  broad  ligament,  the  history  of 
such  differs  so  much  from  the  ordinary  subperitoneal  variety  that  a 
special  notice  is  quite  necessary.  Fibromata  situated  in  this  position, 
instead  of  becoming  pedunculated,  extend  out- 
ward between  the  folds  of  the  broad  ligament 
and  di'op  down  deep  into  the  pelvis.  It  is  not 
until  they  become  quite  large  that  they  extend 
up  out  of  the  pelvis.  Being  surrounded  by  the 
folds  of  the  broad  ligament  they  are  more  firm- 
ly fixed  in  the  pelvis  than  other  subperitoneal 
tumors,  and  consequently  cause  more  displace- 
ment of  the  pelvic  organs.  The  uterus  and  the 
Fig.  173.— Subperitoneal  bladder  are  usually  pushed  far  over  to  the  oppo- 

and  submucous  fibro-      •,        •  i        j!    ,i  t    •  i    jsu  ,„ 

mata  (Winckel;.  ^^^^  ^1^6  ^^  ^ti®  pelvis,  and  the  pressure  upon 
the  ovaries  and  pelvic  nerves  made  by  such  a 
tumor  causes  much  pain.  Fibromata  in  this  position  cause  the  most 
suffering  of  any  of  this  class  of  tumors,  and  they  are  more  likely  to 
cause  cellulitis  than  when  located  elsewhere.  In  some  cases  the  tu- 
mor drops  down  very  lew  in  the  pelvis  behind  all  the  pelvic  organs. 
One  case  of  an  unusually  large  fibroma  which  came  under  my  care 
had  a  large  mass  behind  the  rectum  which  extended  down  to  the 
peritonaeum.  It  appeared  to  be  a  part  of  the  tumor,  but  I  presumed 
that  it  must  be  something  else.  Dr.  Thomas  Keith  saw  the  case, 
and  pointed  out  that  the  tumor  had  split  up  the  broad  Hgament  in 
its  growth,  and  extending  downward  beneath  the  peritonaeum  neces- 
sarily got  behind  the  rectum. 

The  location  of  the  tumor  has  a  marked  influence  upon  its  his- 


350 


DISEASES  OF   WOMEN. 


tory  .itkI  treatment ;  tlie  classification  should  be  clearly  understood 
and  kept  in  mind  on  this  account.  Those  that  grow  toward  the  in- 
side of  the  uterus 
may  remain  l^road- 
ly  attached  to  the 
uterine  wall  or  they 
may  become  pe- 
dunculated. Fig. 
174  shows  this  lat- 
ter condition. 

They  may  be 
single,  conglomer- 
ate, or  multiple. 
The  single  tumor 
consists  of  one 
mass,  the  multi])le 
of  several  masses 
situated  apart  and 
at  different  places 
in  the  uterus,  and 
the  conglomerate 
consists  of  a  num- 
ber of  masses 
growing  close  to- 
gether and  sur- 
rounded by  one 
capsule. 

These  growths 
occur,  as  a  rule,  in 
the  body  and  fun- 
dus of  the  uterus, 
rarely  in  the  cervix.      They  vary  greatly  in   shape.      "When  ver\' 
small  they  are  usually  round,  but  as  they  grow  the}-  sometimes  l)e- 
come  irregular,  especially  is  this  true  of  the  conglomerate  variety. 

In  all  cases  the  tumor  is  in  a  sense  distinct  from  the  wall  of  the 
uterus.  The  tumor  is  in  the  uterine  wall,  but  not  a  part  of  it. 
There  is  in  almost  all  cases  a  clear  line  of  demarkation  between  the 
tumor  and  the  tissues  of  the  wall  of  the  uterus.  The  tissues  which 
surround  the  tumor  and  separate  it  from  the  neighboring  tissues  are 
chiefly  cellular,  and  are  called  the  capsule.  This,  after  all,  is  only  a 
separation  in  the  ari-angement  of  the  tissues  of  the  uterine  wall  and 
tumor  which  shows  the  difference  between  the  two.     Were  it  not 


Fir..  174. — Pedunculated  submucous  fibroid  (Simpson). 


FIBROMA   OF  THE   UTERUS.  351 

for  this  the  morbid  growtli  would  be  very  mucli  like  circumscribed 
hypertrophy  of  the  uterus.  As  it  is,  the  development,  growtli,  and 
decay  of  fibroids  are  influenced  by  the  uterus,  from  which  they  take 
their  origin  and  nutrition,  and  are  governed  by  the  same  laws. 

Fibroids  occur  only  during  the  active  functional  life  of  the 
uterus.  They  increase  in  size  during  pregnancy,  and  generally 
diminish  in  size  after  confinement,  and  after  the  menopause  they 
often  disappear  with  the  final  atrophy  of  the  uterus.  Even  in  the 
absence  of  pregnancy  the  growth  of  a  fibroma  resembles  the  normal 
growth  of  a  jiregnaut  uterus,  in  the  respect  that  there  is  simply  an 
increase  of  tissue  without  change  of  structure.  The  rule  is  that 
fibroids  are  never  seen  bsfore  puberty,  and  they  usually  disappear 
after  the  menopause,  but  not  always  immediately  after  the  cessation 
of  the  menstrual  function.  Usually,  the  menopause  is  postponed  in 
cases  of  fibroma,  the  patient  continuing  to  menstruate  until  fifty 
years  and  over.  Neither  does  the  decrease  in  the  the  tumor  begin 
as  soon  as  the  menses  stop  in  all  cases.  On  the  contrary,  the  organic 
forces  which  maintained  the  menstrual  function  being  no  longer 
called  for  are  devoted  to  the  growth  of  the  fibroma,  and  this  growth 
may  go  on  for  some  time  after  the  menopause,  but  the  rule  is  that 
in  time  the  process  of  atrophy  begins  and  the  tumor  diminishes,  and 
finally  disappears,  or  nearly  so. 

During  the  growth  of  these  tumors  they  frequently  change  their 
position  and  relations  to  the  uterus.  The  submucous  tumor  extends 
more  and  more  into  the  cavity  of  the  uterus.  This  change  in  posi- 
tion diminishes  the  area  of  connection  between  the  tumor  and  uterus. 
It  becomes  pedunculated,  and  in  this  condition  is  sometimes  de- 
scribed as  a  fibrous  polypus  of  the  uterus.  This  process  of  expulsion 
of  the  tumor  fi'om  the  uterus  may  go  on  until  separation  is  com- 
plete, the  tumor  being  expelled  as  is  an  ovum  in  miscarriage.  Fig. 
174  shows  this.  The  same  changes  occur  in  the  reverse  direction  in 
subperitoneal  fibromata.  They  frequently  become  pedunculated, 
and  it  has  happened  that  they  have  become  detached  from  the 
uterus  altogether.  When  this  has  occurred  (which  has  not  been 
often)  there  are  usually  found  adhesions  of  the  tumor  to  the  ab- 
dominal viscera,  and  a  vascular  communication  between  the  tumor 
and  the  parts  to  which  it  has  become  attached  has  been  established. 
Sometimes  such  adhesions  occur  in  tumors  which  are  not  peduncu- 
lated, but  it  is  a  notable  fact  that  fibrom.ata  are  the  least  liable  to 
form  adhesions  of  all  the  neoplasms. 

There  are  certain  facts  in  the  clinical  history  of  fibromata  regard- 
ing their  growth  and  decay,  which  should  be  noticed.     It  has  al- 


352  DISEASES   OF   WOMEN. 

ready  been  stated  that  we  should  expect  that  these  fibromata,  ]>einp; 
like  the  uteriKs  in  structure  and  depending  u])i>n  it  for  nutrition, 
would  liave  many  features  in  c<jmmon  with  tlie  uterus,  and  such  is 
the  case.  The  growtli  and  decay  of  libroids  arc  subject  tu  the  same 
laws  and  iiiHuences  as  the  uterus. 

The  density  of  fibromata  differs  in  different  cases,  and  it  also 
changes  in  the  same  case.  They  sometimes,  esjjccially  if  laige,  be- 
come soft  and  oedematous.  Sometimes  collections  of  serum,  blood, 
or  ])us  are  found  in  the  tumor.  These  give  a  feeling  of  softness  and 
ill-delincd  fluctuation.  When  this  condition  is  found  the  tumor  is 
usually  called  a  fibro-cyst,  but  there  is  a  difference  in  pathology  be- 
tween a  fibro-cyst  and  a  fibroma  with  cyst-like  cavities  containing 
blood,  pus,  and  serum. 

I  have  seen  two  cases  of  fibroma  which  gave  tlie  physical  signs 
of  fibro-cysts.  They  were  both  large  su1)mucous  fibroids,  and  both 
were  situated  in  the  body  of  the  uterus  leaving  the  fundus  free. 
The  tumor  closed  the  lower  part  of  the  cervix  uteri,  and  the  men- 
stnial  fluid  and  secretions  of  the  mucous  membrane  accunmlated  in 
the  fundus  and  upper  part  of  the  cavity  of  the  body,  and  forined 
what  appeared  to  be  in  every  way  a  fibro-cyst. 

After  the  menopause  these  fibromata  usually  diminish  or  remain 
stationary  and  give  no  trouble,  exce^^t  by  mechanical  action  ui)on 
neighboring  organs.  The  rule  is  that  they  either  disappear  or  at 
least  give  no  further  trouble.  xVt  one  time  it  was  believed  that 
fibromata  were  capable  of  being  converted  into  cancer.  That  is  a 
mistake,  I  believe.  Malignant  disease  may  appear  in  connection 
with  fibromata,  but  I  have  not  yet  found  any  reliable  evidence  that 
the  one  is  converted  into  the  other. 

Perhaps  fatty  transformation  is  the  usual  change  which  take- 
place  ;  occasionally,  calcareous  or  osseous  degeneration  occurs. 
Tumors  which  have  undergone  calcai-eous  degeneration  I  have  seen 
several  times,  but  I  have  not  seen  anything  like  true  osseous  forma- 
tions. Perhaps  it  would  express  the  facts  better  in  most  cases  to 
call  this  material  bone-like  rather  than  to  convey  the  idea  that  it  is 
true  bone.  These  changes  or  degenerations  in  fibromata  usually  are 
conservative.  First  the  tumor  stops  growing,  and  then  undergoes 
atrophy,  or  is  transformed  into  osseous-like  or  calcareous  material, 
but  in  either  case  the  rule  is  that  the  patient  is  relieved.  I  believe 
that  in  some  rare  cases  the  tissues  soften  and  suppurate,  and  septi- 
caemia is  produced.  One  such  case  occurred  in  my  practice  and 
proved  fatal. 


FIBROMA   OF  THE   UTERUS.  353 


CHANGES     IN     THE     UTERUS     FROM     THE     EFFECTS     OF     FI- 
BROMATA. 

The  pathological  clianges  which  take  place  in  the  litems  dur- 
ing the  presence  of  a  libroma  ai'e  of  much  interest.  It  becomes 
enlarged  in  all  cases,  but  most  of  all  in  the  submucous  and  inter- 
stitial varieties,  less  so  in  the  subperitoneal,  and  least  in  the 
pedunculated  subperitoneal.  Certain  changes  in  the  mucous  mem- 
brane of  the  uterus  usually  occur.  There  are,  in  many  cases,  poly- 
poid growths  developed,  and  endometritis  is  ahnost  always  present. 

In  regard  to  the  changes  in  the  mucous  membrane,  which  occur 
in  connection  with  iibroma.  Dr.  Wyder,  of  Berlin,  makes  the  follow- 
ing statement : 

"  Fibro-myomas  are  said  to  be  likely  to  give  rise  to  malignant 
diseases  of  the  mucous  membrane.  Martin  has  formerly  maintained 
that  these  conditions  furnish  an  indication  for  total  extirpation.  The 
reader,  having  examined  a  number  of  cases,  does  not  share  this  view. 

"  With  subperitoneal  myomas,  the  mucous  membrane  was  found 
much  thickened ;  the  most  important  alteration  was  a  very  perfect 
glandular  endometritis.  In  one  case,  adenomatous  polypi  were  pres- 
ent ;  in  another,  on  one  side  glandular,  on  the  opjDOsite  side  inter- 
stitial endometritis. 

"  For  interstitial  myomas,  three  groups  must  be  formed  : 

"  1.  Where  the  tumors  are  separated  from  the  uterine  cavity  by 
a  wall  one  half  to  one  centimetre  thick. 

"2.  Where  the  tumor  is  beneath  the  mucous  membrane  but  does 
not  project. 

"  3.  Where  the  tumor  projects  largely  into  the  uterine  cavity. 

"•  Of  seven  cases  in  the  first  group,  in  one  no  alterations  were 
found;  in  two,  glandular  endometritis  (mucosa  four  to  ten  milli- 
metres thick) ;  in  three,  interstitial  endometritis.  In  most  cases  the 
vessels  were  very  numerous,  and  their  walls  very  thick, 

"In  the  second  group,  the  deeper  layers  of  the  mucous  mem- 
brane were  completely  transformed  into  connective-tissue  trabeculie  ; 
at  the  surface  was  a  greatly  dilated  capillary  network  with  thick- 
walled  vessels. 

"  In  the  third  group,  interstitial  endometritis  was  found. 

"  The  thicker  the  wall  separating  the  tumor  from  the  uterine 
cavity  the  more  is  the  glandular  structure  developed  (glandular  en- 
dometritis') ;  the  closer  the  tumor  approaches  the  mncous  membrane 
the  more  pronounced  becomes  the  connective-tissue  character  of  the 
proliferation  in  the  mucosa  (interstitial  endometritis).  We  then 
24 


354  DISEASES   OF   WOMEN. 

find  tlie  mucosa  on  one  side  atropliied  into  citniiective  tissue,  and  on 
the  other  in  a  state  of  ghmduhir  j)roliferation.  As  regards  the 
source  of  the  hiiMuorrhages,  it  should  be  remarked  that  no  vaj>cular 
changes  are  to  be  expected  in  subperitoneal  tumors.  It  was  found 
that,  where  glandular  endometritis  wa.s  alone  present,  no  hiiMiior- 
rhages  had  gone  before.  In  the  case  of  interstitial  tumors  associated 
with  glandular  endometritis  exclusively,  tliere  was  likewise  no  j»re- 
cediug  luLMnorrhage.  It  was  present  only  with  interstitial  en- 
dometritis. Therefore,  haemorrhage  will  not  take  place  where  the 
interglandular  tissue  is  quite  intact ;  Init  it  will  occur  where  both 
structures  proliferate  equally  (endometritis  fungosa),  or  where  one 
or  the  other  form  develops  predominantly,  or  where  glandular  en- 
dometritis exists  on  one  side  and  interstitial  endometritis  on  the 
otber.  Compression  of  the  numerous  vessels  causes  venous  con- 
gestion ;  haemorrhage  will  set  in,  especially  when  glands  and  tissue 
have  proliferated  equally.  The  glands  exert  no  influence  on  the 
under  surface  ;  their  cliuracter  is  usually  benign.  The  border-line 
between  mucosa  and  muscle  is  intact.  Endometritis  glandularis  is 
of  a  benign  nature." 

These  pathological  changes  in  the  mucous  membrane  and  the 
increase  in  its  extent  by  the  great  enlargement  of  the  uterus,  cause  a 
marked  increase  in  the  vascularity.  To  this  state  is  due  the  menor- 
rliagia  and  hciemorrhage  which  are  so  generally  present  in  cases  of 
fibromata.  Deformity  of  the  uterus  is  produced  in  many  cases,  but 
in  some  even  large  tumors  tlie  uterus  presents  the  form  of  that  of 
pregnancy.  It  is  simply  enlarged  but  not  changed  in  form.  There 
is  often  displacement  of  the  utenis,  especially  in  the  interstitial  and 
subperitoneal  varieties.  The  tumor  either  drags  the  uterus  toward 
the  side  upon  which  it  is  located,  if  it  is  small,  or  pushes  the  uterus 
in  the  other  direction,  if  the  growth  is  large. 

The  cervix  uteri  may  be  disturbed  in  many  ways.  It  is  some- 
times greatly  elongated  and  far  out  of  its  normal  position.  Many 
times  it  is  spread  out  on  the  tumor  so  that  it  appears  to  be  a  part  of 
it.  The  canal  of  the  cervix  is  often  tortuous  and  its  caliber  lessened. 
The  effects  of  fibroma  of  the  uterus  upon  surrounding  organs  are 
due  to  pressure  which  may  cause  derangement  of  function.  These 
effects  depend  upon  the  size  and  location  of  the  tumor,  with  refer- 
ence to  the  degree  of  the  derangement.  "When  the  tumor  is  still 
small  enough  to  remain  in  the  pelvic  cavity  and  make  pressure  to  a 
limited  extent  only,  the  symptoms  j^roduced  resemble  those  caused 
by  uterine  displacements  and  small  ovarian  cj^sts.  The  rectum  may 
be  pressed  upon  and  its  function  perverted.     The  bladder  may  suf- 


FIBROMA   OF  THE   UTERUS.  355 

fer  from  pressure  winch  may  prevent  it  from  distending,  or  it  may 
be  rendered  irritable  and  tender  from  pressure.  In  some  cases  the 
pressure  may  become  so  great  that  the  function  of  the  bladder  and 
rectum  may  suffer,  and  even  the  ureters  themselves  may  be  affected 
in  the  same  way.  I  have  seen  several  cases,  three,  in  all,  I  think, 
where  the  ureters  were  obstructed  from  the  pressure  of  fibromata, 
and  the  kidneys  were  affected  in  consequence.  The  pressure  may 
become  so  great  that  the  function  of  the  rectum  or  bladder  becomes 
arrested,  and  inflammation  of  the  cellular  tissue  or  peritonaeum  may 
occur  and  prove  fatal.  I  have  repeatedly  seen  slight  attacks  of  pel- 
vic inflammation  caused  by  pressure  of  fibromata  ;  one  case  proved 
fatal  from  pelvic  inflammation  and  rectal  obstruction.  I  saw  the 
patient  first  when  she  began  to  have  inflammation,  and  I  found  the 
tumor  impacted  in  the  pelvis  and  it  could  not  be  dislodged  by  any 
means.  The  inflammation  progressed,  and  the  obstruction  of  the 
rectum  became  complete  by  the  addition  to  the  tumor  of  the  prod- 
ucts of  the  inflammation.  In  most  cases  the  tumor  can  be  raised 
up  out  of  the  pelvis  when  it  becomes  large  enough  to  give  much 
trouble  by  pressure.  The  pressure  may  be  directed  upon  the  pelvic 
nerves  so  as  to  cause  very  great  pain.  When  fibromata  escape  from 
the  pelvic  to  the  abdominal  cavity,  they  do  not  cause  so  much 
trouble  unless  they  become  very  large.  They  may  cause  peritonitis 
and  intestinal  obstruction,  but  that  is  rare.  They  were  supposed  to 
cause  ascites,  because  fluid  in  the  peritoneal  cavity  was  found  in  a 
certain  proportion  of  cases.  Keith  believes  that  this  fluid  is  a  trans- 
udation from  the  tumor  rather  than  from  the  peritonfeum,  as  in  or- 
dinary ascites.  The  quantity  of  the  fluid  is  seldom  sufficient  to  cause 
much  trouble. 

Symptomatology. — The  symptoms  of  uterine  fibromata  are  natu- 
rally of  three  kinds :  First,  those  manifested  by  the  general  system, 
which  are  also  called  constitutional  or  remote ;  second,  those  which 
originate  in  the  uterus  itself ;  and,  third,  those  that  are  produced  by 
the  pressure  of  the  tumor  upon  neighboring  organs.  The  severity  of 
tlie  remote  symptoms  depends  upon  the  size  and  location  of  the  tu- 
mor. There  are  a  great  many  patients  who  do  not  suffer  in  general 
health  from  fibromata  of  the  uterus  until  the  growth  has  advanced 
to  a  considerable  size.  Sooner  or  later,  according  to  the  extent  of 
disturbance  which  the  growth  causes,  the  general  health  becomes 
impaired.  The  patient  becomes  anaemic  and  is  generally  debilitated, 
because  of  either  the  loss  of  blood  or  deranged  nutrition,  or  both. 
These  symptoms  are  not  by  any  means  diagnostic,  but  may  come 
from  a  variety  of  affections.     In  the  most  marked  cases,  when  the 


356  DISEASES   OF   WOMEN. 

patient  is  extrciiiely  aninnic,  the  skin  becomes  slii^litly  bronzed,  and 
gives  to  tlic  patient  tlie  appearance  of  having  malignant  disease. 
The  symptoms  which  are  manifested  by  the  uterus  are  pain  and 
htemorrhage.  Tlie  pain  is  not  always  pronounced,  in  some  cases  it 
is  not  at  all  ])crsistent.  It  is  irregular,  spasmodic  in  character,  and 
is  most  marked  when  the  tumor  is  submucous,  and  least  so  in  the 
interstitial  variety.  The  haemorrhage  is  the  most  prominent  symj)- 
toni  of  all.  It  usually  comes  on  periodically,  and  is,  therefore,  in 
some  cases  a  monorrhagia.  ^Menstruation  is  too  free,  and  lasts  too 
long,  and  recurs  too  often.  Bleeding  may  come  at  any  time,  there 
being  no  regularity  whatever  in  some  ca.ses.  This  symptom  is  so 
constantly  present,  that  Dr.  J.  Mathews  Duncan  called  fibroma  the 
bleeding  disease  of  the  uterus. 

This  nanie  is  w^ell  deserved,  for  certainly  no  other  affection  gives 
rise  to  so  much  haemorrhage  of  the  uterus  as  does  this.  The  size 
of  the  tumor  does  not  influence  the  severity  of  the  l)leediiig.  In 
some  small  tumors  the  bleeding  is  greater  than  in  others  of  mon- 
strous size.  It  is  the  location  of  the  tumor  which  determines  the 
baemorrhagic  symptoms.  It  is  greatest  in  the  submucous,  less  in  the 
interstitial,  and  least  in  the  subperitoneal  as  a  general  rule.  The 
submucous  pedunculated  variety  is  the  worst  of  all  for  causing 
bleeding.  A  very  small  tumor  of  this  kind  may  cause  the  most 
persistent  and  exhausting  haemorrhage.  The  symptoms  caused  Ijy 
the  effect  of  the  tumor  upon  neighbormg  organs  are  generally  most 
marked  when  the  tumor  occupies  the  pelvic  cavity.  Then  the  press- 
ure upon  the  bladder  and  rectum  causes  irritation  and  functional  ol> 
struction  of  these  organs  ;  less  or  more  pelvic  tenesmus  of  a  general 
character  is  sometimes  very  severe.  The  effect  upon  the  bladder  is 
to  render  urination  very  frequent  and  sometimes  difficult  or  impossi- 
ble. I  have  seen  three  cases  in  which  there  was  retention  of  urine. 
The  tumor  was  pear-shaped  in  all  of  them,  and  large  enough  to  ex- 
tend above  the  brim  of  the  pelvis.  The  urethra  and  bladder  were 
carried  upward,  so  that  the  urethra  was  caught  between  the  tumor 
and  pelvis,  and  compressed.  Urination  in  these  cases  was,  for  a 
time  difficult,  and  then  retention  came.  All  voluntai'y  efforts  to 
evacuate  the  bladder  only  made  matters  worse,  by  forcing  the  tumor 
downward  and  wedging  it  into  the  su])erior  strait.  Relief  was  given 
first  by  the  catheter,  and  then  by  ])ushing  the  tumor  upward,  the  pa- 
tient being  placed  in  the  knee-chest  position.  Pressure  upon  the  pel- 
vic nerves  and  ovaries  often  causes  much  pam.  Pain  in  the  back  and 
limbs,  which  is  often  present,  no  doubt  comes  from  the  same  cause. 

Pressure  upon  the  ureters  may  cause    obstruction    and  hydro- 


FIBROMA   OF  THE    UTERUS.  357 

neplirosis,  and  all  the  unfortunate  results  to  the  kidney  which  must 
follow.  In  such  cases  there  is  at  first  pain  in  the  region  of  the 
ureters,  and  subsequently  the  symptoms  of  renal  disease  appear. 
Fibromata  large  enough  to  occupy  the  cavity  of  the  abdomen  give 
very  little  trouble,  as  a  rule.  So  far  as  affecting  the  neighboring 
organs,  very  large  tumors  interfere  with  free  respiration,  and  the 
action  of  the  stomach  and  bowels  to  some  extent.  The  ascites  which 
sometimes  accompanies  fibromata  of  the  uterus  was  supposed  to  be 
due  to  irritation  of  the  peritonaeum.  It  is  more  likely  that  it  is  a 
transudation  from  the  tumor  itself,  as  already  stated.  This  is  sug- 
gested by  the  fact  that  hydro-peritonaeum  is  usually  found  in  connec- 
tion with  oedematous  tumors. 

Physical  Signs. — The  positive  signs  of  fibroma  are  the  increase 
in  size,  change  in  form,  and  consistence  of  the  uterus,  and  the  dis- 
placement or  distention  of  the  canal,  as  related  to  the  body  of  the 
uterus.  The  touch  discovers  the  fact  that  the  uterus  is  enlarged, 
apparently,  and  by  the  bimanual  touch  it  usually  can  be  proved  to 
bo  really  so.  The  shape  of  the  uterus  is  changed  in  nearly  all  cases. 
It  is  irregular  in  outline,  one  side  being  much  larger  than  the  other. 
In  the  subj^eritoneal  variety,  this  deformity  is  quite  marked.  The 
tumor  projects  from  the  surface  of  the  uterus  so  boldly  that  it  can 
be  instantly  detected.  In  some  of  the  cases  of  submucous  fibroma, 
and  occasionally  in  the  interstitial,  the  uterus  is  uniform  in  shape, 
and  appears  like  a  uterus  enlarged  by  gestation,  and  even  when 
there  is  some  irregularity  of  form  it  is  not  unlike  that  which  is  often 
found  in  pregnancy,  but  the  uterus  is  very  hard  in  the  one  case, 
while  in  the  other  it  is  very  soft.  The  hard  character  of  the  tumor 
and  uterus  is  a  very  reliable  sign  of  fibroma.  In  all  conditions  which 
cause  enlargement,  the  uterus  is  softened  except  in  fibroma  and  in 
very  rare  cases  of  cancer.  Whenever  the  uterus  is  enlarged  and  in- 
durated, fibroma  may  be  strongly  suspected. 

Deflection  of  the  canal  of  the  uterus  from  the  center  is  a  very 
important  sign  of  fibroma.  The  relations  of  the  canal  of  the  uterus 
to  the  axis  of  the  pelvis,  as  shown  by  the  sound,  are  changed  in  all 
forms  of  displacement,  but  the  canal  is  still  in  the  center  of  the 
uterus.  In  fibroma  the  canal  is  excentric  and  very  often  tortuous. 
The  use  of  the  sound,  by  which  this  displacement  of  the  uterine 
canal  can  be  detected,  gives  this  most  valuable  evidence  of  the  ex- 
istence of  a  fibroma.  Figs.  175  and  176  will  show  this  point  very 
plainly.  The  one  shows  a  uterus  large,  owing  to  subinvolution, 
the  other  about  the  same  size  from  enlargement  due  to  a  fibroid. 

In  not  a  few  cases  the  canal  is  so  deflected,  displaced,  or  com- 


358 


DISEASES  OF   WOMEN. 


i 


Fig.  175.  Fig.  176. 

Figs.  175,  176. — Enlargement  due  to  subinvo- 
lution compared  with  tliat  from  growth  of 
a  fibroma  (after  Wincliei). 


))ressed,  that  the  sound  can  not  be  passed.     A  flexible  l)ou^ie  may 
be  used,  under  these  cireunistances,  and  altliough  it  will  not  posi. 

tively  show  the  position  of  the 
canal  it  gives  valuable  indica- 
tions of  it.  When  the  sound 
can  not  be  used  at  all,  this  valu- 
able sign  is  not  obtainable,  but 
the  fact  that  the  canal  in  a  hirjie 
uterus  will  not  admit  the  sound 
is  evidence  of  fibroma.  There 
is  no  other  condition  of  enlarge- 
ment of  the  uterus  in  which  the 
sound  can  not  be  passed,  as  a 
rule. 

Small  fibromata,  which  oc- 
cupy the  pelvic  cavity,  present 
some  physical  signs  which  resemble  displacements  of  the  uterus, 
ovarian  tumors,  tubal  pregnancy,  the  products  of  former  inflamma- 
tions and  diseases  of  the  Fallopian  tubes. 

The  differentiation  between  flexions  and  versions  of  the  utenis 
and  fibromata  is  based  upon  the  following  facts :  In  flexion  and 
version  the  uterus  is  not  much  enlarged,  and,  as  a  rule,  can  be  re- 
stored to  the  proper  position  when  all  signs  suggestive  of  liljroina 
disappear,  and  then,  too,  the  sound  shows  that  the  cavity  of  the 
uterus  is  not  displaced  nor  enlarged.  Ovarian  tumors  are  distin- 
guished from  fil)romata  by  being  less  dense  and  not  usually  fixed  to 
the  utenis ;  one  can  be  moved  without  the  other.  Early  pregnancy 
is  usually  distinguished  from  a  fibroma  by  the  history  and  synij)- 
toms,  but  the  physical  signs  dift'er.  The  uterus  is  soft  in  pregnancy, 
while  it  is  unduly  hard  in  fibroma.  The  enlargement  and  softening 
extend  to  the  cervix  in  pregnancy,  bat  not  in  flbroma.  Should  a 
doubt  exist,  the  differential  diagnosis  can  easily  be  made  in  a  short 
time  by  watching  the  progress  of  the  case.  The  signs  of  pregnancy 
will  soon  become  sufficiently  jjronounced  to  settle  the  question. 

The  most  difficult  cases  to  deal  M'ith  arc  those  in  which  preg- 
nancy takes  place  while  there  is  a  fibroma  present ;  I  have  seen  sev- 
eral cases  of  this  kind.  Two  of  these  were  pregnant  when  first  seen, 
and^in  both  the  diagnosis  of  fibroma  was  made  and  in  only  one  did 
I  suspect  pregnancy  at  my  first  examination.  In  the  others  I  was 
aware  of  there  being  a  fibroma  present,  but  I  did  not  detect  the 
pregnane}'  until  several  months  had  elap.sed. 

Fibromata  situated  within  the  folds  of  the  broad  ligament  are  not 


FIBROMA  OF  THE   UTERUS.  359 

easily  distinguished  from  the  products  of  a  pelvic  cellulitis,  extra- 
uterine pregnancy,  and  diseases  of  the  Fallopian  tubes.  The  history 
of  the  case,  taken  in  connection  with  the  physical  signs,  will  usually 
suffice  to  enable  one  to  make  the  diagucjsis. 

Large  fibromata  which  occupy  the  abdominal  cavity  have  to  be 
differentiated  from  fibro-cysts  of  the  uterus  and  ovarian  tumors.  In 
regard  to  the  distinctive  signs  by  which  the  diagnosis  between 
ovarian  tumors  and  fibromata  is  made  the  reader  is  referred  to  the 
section  relating  to  the  diagnosis  of  ovarian  tumors. 

The  solid  hard  iibroma  is  easily  distinguished  from  a  fibro-cyst  of 
the  uterus  by  its  density,  as  recognized  by  the  touch,  but  a  soft 
fibroid  may  be  so  elastic  as  to  give  the  signs  of  an  imperfect  fluctua- 
tion, and  simulate  a  cyst  with  a  thick  wall.  In  such  cases  of  doubt 
the  chances  are  in  favor  of  the  tumor  being  a  soft  fibroma,  but  if  it 
is  very  necessary  to  make  a  diagnosis  it  may  be  done  by  aspiration. 
The  accumulation  of  fluid  in  the  upper  part  of  the  cavity  of  the 
uterus,  occurring  as  a  complication  of  a  uterine  fibroma,  gives  the 
physical  signs  of  a  fibro-cyst  so  perfectly  that  one  must  certainly  be 
led  to  make  a  false  diagnosis.  I  have  seen  two  such  cases,  one  was 
a  very  large  intra-uterine  fibroma  which  closed  the  canal  of  the 
uterus  below  by  pressure  in  the  latter  stages  of  its  growth.  The 
secretions  of  the  mucous  membrane  accumulated  at  the  fundus  and 
gave  distinct  fluctuation.  One  of  the  most  distinguished  gyne- 
cologists of  this  age  saw  the  patient  with  me  and  thought  as  I  did 
that  it  was  a  fibro-cyst,  but  it  was  not. 

The  histories  of  these  eases,  especially  one  which  is  given  further 
on,  will  show  more  fully  the  peculiar  character  of  the  pathology  and 
the  difficulties  of  diagnosis. 

Causation. — Yery  little,  if  anything,  is  known  about  the  true 
pathogenesis  of  uterine  fibroma ;  certain  facts  in  regard  to  age,  race, 
and  social  relations  have  been  ascertained  which  favor  the  occur- 
rence of  these  neoplasms.  The  age  when  women  are  most  liable  to 
these  growths  is  between  thirty  and  thirty-five  years.  There  are 
many  exceptions  to  this,  however,  but  it  is  rare  to  have  these  growths 
come  before  puberty  or  after  the  menopause.  It  may  be  more  cor- 
rect to  say  that  they  never  occur  before  puberty  and  rarely  after  the 
menopause.  In  regard  to  race,  the  negro  is  more  liable  to  fibromata 
than  the  white,  although  no  good  reason  has  been  discovered  why 
this  is  the  case.  The  influence  of  the  social  relations  is  stated  by 
Thomas  Addis  Emmet  as  follows  : 

"  The  development  of  these  growths  is  retarded  by  child-bearing, 
and  even  by  marriage,  for  the  sterile  woman  is  less  liable  than  the 


360  DISEASES  OF   WOMEN. 

old  iiuiid,  but  ill  turn  she  is  more  t^o  than  the  woman  who  has  borne 
cliildren."  These  facts  are  deductions  from  large  tabulated  observa- 
tions of  ca^es  by  Dr.  Emmet,  and  are  therefore  reliable.  He  also 
gives  his  views  regarding  these  social  states  as  related  to  the  causor 
tion  of  these  neoplasms,  in  the  following : 

"  Uetween  the  ages  of  thirty  and  forty  yeai-s  the  unmarried 
woman  is  fully  twice  as  subject  to  fibrous  tumors  as  tlie  sterile  or 
the  fruitful.  I  have  already  referred  to  this  subject,  when  treating 
of  the  causes  of  disease,  and  pointed  out  that  this  Ls  one  of  the 
tributes  which  an  unmarried  woman  pays  for  lier  celibacy.  It  seems 
as  if  it  were  the  purpose  of  Nature  that  the  uterus  should  undergo 
the  changes  dependent  upon  pregnancy  and  lactation  about  once  in 
three  yeai-s  throughout  the  child-bearing  period,  and  that  if  the 
uterus  is  not  physiologically  occupied  in  child-bearing  there  is  greater 
lial)ility  to  the  development  of  fibrous  tumors  as  the  woman  advances 
in  life.  This  will  also  be  the  case  with  the  married  woman  who  has 
taken  means  to  prevent  conception,  as  well  as  with  her  who  has  been 
sterile  from  some  cause  beyond  her  control,  but  to  a  less  degree  in 
the  latter  case.  I  think  I  have  had  occasion  to  note  that  the  sterile 
woman  who  has  earnestly  wished  for  children  does  not  have  her 
liability  to  fibrous  tumor  increased  by  the  fact  of  her  sterility,  an 
instance,  probably,  of  the  remarkable  effect  of  mind  upon  the  body. 
Finally,  the  woman  who  may  have  been  fruitful  in  early  life,  but 
remained  sterile  long  afterward,  from  some  accidental  cause,  may 
have  a  tumor  developed,  but  is  less  liable  thereto  from  having  once 
borne  a  child." 

Prognosis. — Fibromata  of  the  uterus,  while  the  most  fre(piently 
seen  of  all  the  neoplasms  of  the  sexiial  organs,  are  the  most  harmless 
so  far  as  their  tendency  to  destroy  life.  They  occasionally  prove 
fatal,  but  many  cases  progress  until  the  menopause,  when  the 
growths  disappear  altogether  or  become  reduced  during  the  tinal 
involution  of  the  uterus,  so  that  they  are  harmless. 

The  dangers  are,  first,  haemorrhage,  which  recui*s  so  often  in 
many  cases  that  it  endangers  life.  Very  few  patients  bleed  to  death 
directly,  l)ut  some  become  so  reduced  by  the  long-continued  loss  of 
blood,  which  impairs  nutrition,  that  death  conies  as  the  result  of  some 
secondary  affection  which  would  not  have  occurred  except  for  the 
exhausted  state  of  the  patient.  Peritonitis  and  cellulitis  are  liable 
to  be  set  up  by  fibromata,  and  of  the  fatal  cases  peritonitis  is  a  not 
infrequent  cause.  Softening  of  the  tumor  and  decomposition  may 
cause  a  fatal  septicaemia.  Blood-poisoning  sometimes  occurs  during 
the  expulsion  of  extra-uterine  fibroma.     Tlie  tumor  being  in  part 


FIBROMA   OF   THE    UTERUS.  361 

cut  off  from  the  circulation  undergoes  necrosis  before  its  expulsion 
is  coniplcted,  and  causes  septiciemia,  and  death  takes  place  when 
rehef  and  recovery  appear  to  be  witliin  the  immediate  reach  of  the 
sufferer.  Pressure  upon  the  pelvic  organs  may  cause  death  by  arrest- 
ino-  the  functions  of  these  organs.  This  is  most  likely  to  take  place 
when  the  tumor  grows  in  the  In-oad  ligament  and  is  therefore  fixed 
in  the  pelvis.  1  have  also  seen  death  occur  from  pressure  upon  the 
ureters  causing  obstruction  to  the  lluw  of  urine,  renal  disease,  and 
finally  urcemia.  Although  there  are  dangers  from  all  of  the  com- 
plications named  above,  a  very  small  percentage  proves  fatal  even 
when  left  without  treatment ;  and  by  judicious  management  a  large 
nuinber  can  be  relieved  entirely  or  helped  sufficiently  to  be  able 
to  pass  through  life  in  comparative  comfort.  Within  the  past  few 
years  such  means  as  ovariotomy,  hysterectomy,  and  electrolysis 
have  been  employed  in  the  treatment  of  uterine  fibroma,  with  re- 
sults which  raise  the  hope  that  the  great  majority  of  these  neo- 
plasms will  be  controlled,  and  the  death-rate  from  this  cause  re- 
duced to  a  minimum. 

Treatment. — The  size  and  location  of  uterine  filDromata,  and  the 
conditions  and  complications  produced  by  them  differ  very  greatly, 
and  hence  the  treatment  must  vary  with  each  case.  The  ways  and 
means  may  be  said  to  vary  from  the  simplest  medication  to  the  most 
daring  surgery,  and  each  method,  if  judiciously  adapted  to  the  re- 
quirements of  cases  as  they  come,  gives  satisfactory  results. 

Medicinal  agents  have  been  employed  in  great  variety,  but  ergot 
alone  has  been  found  of  real  value.  The  action  of  ergot  upon 
fibromata  may  accomplish  beneficial  effects  in  two  ways.  By  excit- 
ing uterine  contractions  it  may  produce  expulsion  of  the  tumor  if 
its  relations  to  the  uterine  wall  are  such  that  it  can  be  expelled. 
On  this  account  ergot  does  its  best  work  in  the  submucous  variety 
of  uterine  fibromata.  In  the  same  way  the  ergot,  by  causing  con- 
traction of  the  uterine  walls,  may  lessen  the  area  of  attachment  of  a 
subj)eritoneal  fibroma,  and  arrest  or  retard  its  growth  by  lessening 
its  blood-supply.  This  view  of  the  beneficial  effects  of  ergot  upon 
the  progress  of  subperitoneal  fibromata,  is  based  upon  the  fact  that 
when  such  tumors  are  pedunculated,  they  do  not,  as  a  rule,  grow  so 
fast  as  wlien  they  are  attached  to  the  uterus  by  a  broad  base.  In 
this  respect,  the  action  of  ergot  is  simply  to  aid  in  the  natural 
method  of  disposing  of  these  growths,  viz.,  by  expulsion,  which  in 
the  submucous  or  intra-uterine  variety  is  often  complete,  the  growth 
being  wholly  exiK^lled  from  the  uterus. 

Ergot  also  acts  in  another  way  to  arrest  the  growth  of  such  tu- 


302  DISEASES  OF    WOMEN. 

mors.  Dy  kcepiu:^  the  utcriLs  in  a  conditiuu  of  pennanunt  contrac- 
tion, and  by  contracting  the  blood-vessels,  the  size  of  the  tumor  is 
diminished,  and  atrophy  takes  place.  In  order  to  obtain  the  good 
ed'ects  of  ergot  in  tliis  way,  it  must  be  given  in  liberal  doses,  suffi- 
cient at  least  to  produce  all  the  contractions  of  the  uterus  that  the 
patient  can  endure  the  pains  of,  and  it  must  l)e  continued  for  a  long 
time.  It  sonietimes  happens  that  the  ])atient  can  not  take  ergot  for 
any  length  of  time  without  having  indigestion  and  loss  of  appetite ; 
occasionally,  also,  the  uterus  fails  to  contract  in  res])onsc  to  full  doses 
of  this  drug.  In  either  case  it  is  useless,  and  should  not  be  con- 
tinued. 

In  some  cases  the  use  of  ergot,  while  it  does  not  diminisli  the 
size  of  the  tumor  nor  aid  in  its  expulsion,  appears  to  retard  its 
growth,  and  it  also  controls  the  bleeding  which  is  a  great  gain. 
When  the  patient  can  be  guarded  against  the  great  loss  of  blood,  she 
may  be  enabled  to  live  in  comparative  comfort  and  usefulness  until 
the  menopause. 

The  menorrhagia  can  sometimes  be  helped  by  treating  the  endo 
metrium. 

The  endometritis  is  often  attended  with  fungous  growths  which 
greatly  increase  the  tendency  to  hosmorrhage.  The  removal  of  such 
fungosities  with  the  curette  will  often  give  relief,  and  the  subse- 
quent application  of  tincture  of  iodine  to  the  uterine  mucous  mem- 
brane at  regular  intervals,  is  of  service.  In  order  to  use  the  cu- 
rette and  apply  the  iodine,  it  is  necessary  that  the  cervical  canal 
should  be  sufficiently  large  to  permit  an  entrance  to  the  uterine 
cavity.  In  some  cases  the  cervical  canal  is  so  narrow  and  the  cavity 
of  the  uterus  so  deflected  that  such  treatment  is  impossible. 

When  expulsion,  with  or  without  the  use  of  ergot,  has  advanced 
far  enough  to  j^edunciilate  an  intra-uterine  tumor  and  dilate  the  cer- 
vix utei-i,  the  tumor  can  be  separated  from  the  uterine  wall  and  re- 
moved by  dividing  the  pedicle.  When  the  dilatation  of  the  cervix 
is  complete,  and  the  tumor  is  expelled  from  the  uterus  and  is  lodged 
in  the  vagina  (the  pedicle  still  remaining  attached  to  the  uterus)  the 
separation  and  removal  of  the  tumor  are  quite  easy. 

There  are  several  methods  of  dividing  the  pedicle.  I  prefer  to 
use  the  wire  ecraseur.  The  galvano-cautery  ecraseur  has  been  used 
but  it  is  difficult  to  apply,  and  it  is  impossible  to  avoid  burning  the 
uterus  and  vagina,  and  has  no  advantages  over  the  wire  or  chain. 

The  ecrasenr  which  I  use  is  modified  to  suit  the  wire.  The  por- 
tion to  which  the  wire  is  attached  is  so  arranged,  that  each  end  of 
the  wire  is  held  fast  by  a  pinching  screw,  so  that  the  loop  of  wire 


FIBROMA   OF   THE   UTERUS. 


363 


can  be  Icngtlieiied  or  shortened  in  a  moment  (Fig.  177).     I  employ 

the  steel  wire  used  for  piano  or  zither  strings,  the  thickness  of  the 

wire  being  adapted  to  the  size  of  the  pedicle.     The  wire  has  one 

very  great  advantage  over  the  chain  in  being 

easily  applied.    It  is  elastic,  and  yet  stift"  enough 

to  be  easily  made  to  slip  over  the  tumor  to  be 

snared. 

Objections  to  the  wire  or  chain  ecraseur 
have  been  raised.  There  is  danger,  it  has  been 
claimed,  of  the  uterine  wall  being  drawn  into 
the  grasp  of  the  chain  and  a  part  of  it  removed, 
and  an  opening  made  directly  into  the  perito- 
neal cavity.  The  fact  is,  that  as  the  wire  is 
tightened  around  the  pedicle,  the  tissues  are 
forced  out  of  its  grasp  equally  on  both  sides. 
There  is  no  drawing  of  the  tissues  into  the 
grasp  of  the  wire. 

If  there  is  inversion  of  the  uterus  at  the 
point  of  the  attachment  of  the  pedicle,  the 
wall  of  the  uterus  might  be  included  in  the 
ecrasevr-whe  and  removed.  This  happened 
once  in  my  own  practice,  and  I  believe  the 
same  thing  has  been  done  by  other  operators. 
Fig.  178  shows  the  condition  referred  to  as  it 
occurred  in  my  own  patient. 

The  inversion  of  the  part  of  the  uterus  was 
not  detected  before  the  operation  was  com- 
pleted, but  an  examination  of  the  tumor 
showed  that  the  inverted  portion  of  the  uter- 
ine  wall  was  completely  removed.  Ko  harm 
came  from  it.  The  patient  did  well,  but  the 
greatest  anxiety  was  felt  for  some  time. 

Sometimes  it  happens  that  the  tumor,  while  it  protrudes  into  the 
vagina  to  a  slight  extent,  is  grasped  by  the  cervix  so  firmly,  that  the 
wire  of  the  ecraseur  can  not  be  applied.  The  same  difficidty  has  been 
encountered  when  the  tumor — the  size  of  a  fetal  head — is  lodged 
in  the  vagina.  Under  such  circumstances,  the  tumor  should  be  re- 
duced by  rapidly  taking  sections  of  it  away  with  a  strong  scissoi"s, 
and  then  the  ecraseur  can  be  used,  or  if  the 
great  the  base  of  the  tumor  can  be  enucleated. 

The  removal  of  the  base  of  a  tumor  is  easily  accomplished  by 
seizing  the  mass  in  the  center  with  a  tenaculum  forceps  and  separat- 


FiG.  177. — Ecraseur. 


litemorrhage  is  not 


364 


DISEASES  OF   WOMKN. 


injj^  it  first  from  tlic  mucous  membrane  which  forms  the  capsule 
and  finally  from  the  muscular  wall.     Much  care  and  ^jjentle  handling 

of  the  enucleating  instrument  should 
"^  X  be  employed,  because  tiie  muscular 

wall  of  the  uterus  at  the  point  of  at- 
tachment of  the  tumor  may  be  ab- 
sorbed, and  the  base  of  the  tumor 
rest  upon  the  peritonseum.  Thi< 
.state  of  affairs  I  have  found  in  two 
cases  which  I  treated  by  enucleation, 
the  histories  of  which  will  be  given. 
Intra-uterine  fil)romataliave  been 
treated  by  dilatation,  or  division  of 
tlie  cervix  uteri  and  enucleation  be- 
fore they  became  pedunculated. 

At  one  time  this  treatment  was 
quite  in  vogue  in  this  country.  The 
operation  is  difficult  and  dangerous. 
The  dangers  are  from  shock,  htem- 
orrhage,  and  septicaemia,  and  so  far 
as  I  can  learn  the  results  have  been 
in  many  cases  unsatisfactory.  Some 
years  ago  I  abandoned  this  method 
for  other  methods  of  treatment  whicli 
I  believe  to  be  less  dangerous  and 
more  effective  in  such  conditions. 
Removal  of  the  ovaries  for  the  relief  of  small  fibromata  which 
cause  exhausting  haemorrhage  has  given  very  satisfactory  results. 
This  plan  of  treatment  was  suggested  by  the  fact  that  these  neo- 
plasms disappear,  as  a  rule,  after  the  menopause.  Reasoning  from 
this  it  was  presumed  that  by  removing  the  ovaries,  and  thereby  in- 
ducing the  cessation  of  the  menstrual  function  prematurely,  the 
same  effect  upon  the  fibromata  would  be  obtained.  Practically,  it 
was  found  to  be  so,  and  hence  in  properly  selected  cases  the  re- 
moval of  the  ovaries  is  the  best  treatment.  In  some  cases,  although 
the  removal  of  the  ovaries  appears  to  be  the  best  means  of  giving  re- 
lief, it  is  found  impractical.  When  the  ovaries  can  not  be  reached 
with  sufficient  ease  to  make  their  removal  possible,  or  when  they  are 
so  closely  adherent  to  the  uterus,  as  they  sometimes  are,  that  they 
would  require  to  Ije  dissected  from  their  attachments  it  is  unsafe  to 
try  to  remove  them.  Under  such  circumstances  it  is  better  to  per- 
form hysterectomy. 


Fig.  1 7S. — Wall  of  uterus  caujjht  in 
ecraseur-wire  and  removed. 


FIBROMA    OF   THE   UTERUS.  365 

It  is  well  in  view  of  these  facts,  to  be  prepared  to  remove  the 
uterus,  when  ovariotomy  is  undertaken  for  the  relief  of  uterine 
fibromata,  for  should  the  one  operation  prove  to  be  impossible  the 
other  could  be  resorted  to.  Beyond  tli/^  fact  that  the  ovaries  ai'c 
sometimes  more  difficult  to  get  at  in  these  cases,  there  is  nothing  in 
the  operation  which  differs  from  ovariotomy  generally,  hence  noth- 
iner  need  be  said  about  it  in  this  connection. 

It  should  be  understood  that  the  exact  value  of  this  method  of 
treatment  is  still  under  consideration,  and  more  time  and  cases  are 
needed  to  settle  the  question  definitely.  All  who  have  practiced 
this  method  of  treatment  often  enough  to  obtain  valuable  experience 
report  favorably  of  it.  Wildow  states,  that  in  seventy-six  cases  the 
menopause  occurred  immediately  in  sixty-one.  In  four  cases,  the 
effect  upon  the  haemorrhage  was  temporary.  In  sixty-three  cases 
the  fibromata  diminished.  In  three  cases  there  was  a  primary 
diminution  and  a  subsequent  increment  of  the  tumor. 

More  recently  Wildow  has  given  the  statistics  of  one  hundred 
and  forty-nine  cases,  of  which  fifteen  died.  I  presume  that  the 
death-rate  has  been  less  than  this  with  some  operators.  Shonld  it 
prove  to  be  so  great  as  ten  per  cent  it  would  become  a  questionable 
procedure,  notwithstanding  that  the  results  in  the  successful  cases 
should  prove  to  be  satisfactory. 

Hysterectomy  for  the  relief  of  uterine  fibromata  has  now  been 
performed  a  sufficient  number  of  times  to  enable  one  to  discuss  its 
relative  merits  with  some  degree  of  certainty. 

In  the  first  place  it  is  adapted  to  large,  rapidly-growing  tumors, 
which  do  not  yield  to  less  heroic  treatment,  but  i-ender  the  patient 
useless  and  threaten  her  life. 

Dr.  Thomas  Keith,  who,  up  to  this  time,  is  by  far  the  most  suc- 
cessful operator,  in  speaking  of  this  subject,  says  : 

"  I  often  ask  myself  the  question :  Does  a  mortality  of  eiglit  per 
cent  justify  an  operation  for  a  disease  that,  as  a  rule,  has  only  a 
limited  active  life,  that  torments  simply,  and  that  only  for  a  time, 
though  of  itself  it  rarely  kills  ?  The  mortality  of  an  ordinary  uter- 
ine fibroid,  if  left  alone,  is  nothing  approaching  a  death-rate  of  eiglit 
per  cent.  I  doubt  even  if  the  mortality  of  the  extreme  cases  exceed 
this.  And,  after  all,  the  great  difficulty  is,  not  in  doing  even  the 
worst  of  these  operations,  but  in  knowing  what  are  the  cases  in 
which  it  is  right  to  advise  those  who  trust  themselves  to  us,  to  run 
the  risk  of  a  dangerous  operation,  with  all  its  attendant  miseries. 
Could  we  get  the  mortality  down  to  five  per  cent  in  the  bad  cases, 
and  these  only  are  the  fit  subjects,  tlien  one  might  advise  interfer- 


300 


DISEASES   OF    WOMEN". 


ence  with  a  more  easy  luiiul.     I  do  not  think  that  we  can  so  advisu. 
if  the  mortality  can  not  be  kept  under  ten  per  cent." 

It  appears  at  the  present  time  that  by  the  judicious  use  of  other 
means  of  treatment  the  number  of  cases  wliich  will  require  liyster- 
ectomv  in  the  future  will  be  diminished,  but  still  there  may  always 
be  some  that  will  demand  it.  Dr.  Keith  says  that  all  his  operations 
were  done  on  account  of  repeated  haemorrhages  and  ruined  health. 
He  also  states  that  the  time  chosen  for  the  operation  was  a  day 
or  two  before  menstruation  was  expected,  because  the  patients  had 
then  regained  more  or  less  force  from  the  loss  of  the  previous 
period. 

Electrohjsis.—Thh  method  takes  the  highest  rank  among  the 
means  of  treating  fibroma  of  the  uterus.  In  order  to  fully  compre- 
hend this  subject,  some  knowledge  of  the  elements  of  electro-physics 
should  be  obtained.  The  following  treatment  of  this  matter  was 
prepared  for  me  by  my  friend  Prof.  Charles  Jewett : 

Some  knowledge  of  electro-physics  is 
essential  to  the  intelligent  use  of  electric- 
ity as  a  therapeutic  agent.  The  limits  of 
this  cliapter,  however,  will  not  permit 
more  than  a  brief  mention  of  such  ele- 
mentary facts  as  are  necessary  to  a  proper 
understanding  of  the  teiTninology  and 
technique  of  electrical  treatment  in  gyn- 
ecology and  a  few  words  of  advice  with 
reference  to  the  selection  of  apparatus. 
For  a  more  extended  knowledge  of  the 
subject  tlie  reader  must  be  referred  to  the 
many  standard  works  on  electrical  science. 
The  physical  forces  are  no  longer  re- 
garded as  having  a  distinct  and  inde- 
pendent existence  and  manifesting  them- 
selves by  their  effects  ujion  matter,  but 
rather  as  affections  or  conditions  of  mat- 
ter itself.  In  short,  the  diffei'ont  physi- 
cal forces  are  different  modes  of  motion 
in  the  molecules  of  bodies.  The  phenom- 
ena of  electricity,  then,  are  due  to  a  mode 
of  molecular  motion.  It  is  an  important  practical  fact  that  the 
molecular  forces  are  mutually  convertible.  Any  one  may  be  trans- 
fonned  into  any  other  force.  Familiar  examples  of  the  conversion 
of  force  are  the  transformation  of  heat  into  light  when  a  bit  of  wire 


-Electrical  action  in  a 
sinfrle  cell. 


FIBROMA   OF   THE    UTERUS.  367 

is  brought  to  incandesccnco  in  a  gas-tluiiio,  the  generation  of  heat  by 
friction  or  impact,  the  production  of  ligiit  by  electricity,  and  so  on. 
Ill  ])ractice,  electricity  is  derived  from  a  variety  of  sources.  The 
electricity  of  a  frietional  machine  is  the  product  of  tlie  mass  motion 
of  the  glass  plate,  or  rather  of  the  muscular  force  expended  in  turn- 
ing the  phite.  Magneto-electricity  is  obtained  from  nuignetisra. 
The  electrical  energy  of  a  galvanic  battery  is  the  result  of  the  chem- 
ical action  of  its  elements.  In  accordance  with  the  law  of  the  cor- 
relation of  forces,  the  amount  of  electrical  energy,  by  whatever 
method  developed,  is  the  mathematical  equivalent  of  the  force  ex- 
pended in  producing  it. 

Galvanism,  faradism,  and  static  electricity  are  the  kinds  of  elec- 
tricity commonly  used  for  therapeutic  purposes.  Galvanism,  for  use 
in  medicine,  is  generally  obtained  from  chemical  sources,  A  simple 
example  of  a  galvanic  cell  may  be  constructed  by  immersing,  at  a 
short  distance  apart,  a  plate  of  gas  carbon  and  one  of  zinc  in  dilute 
hydrochloric  acid  in  a  common  glass  tumbler  (Fig.  179).  A  moment- 
ary chemical  action  takes  place  in  the  cell.  The  chlorine  of  the  acid 
enters  into  combination  with  the  zinc,  forming  the  chloride  of  zinc, 
which  goes  into  solution  in  the  fluid  of  the  cell.  Bubbles  of  free 
hydrogen  collect  upon  the  surface  of  the  carbon  plate.  It  can  now 
be  shown,  by  methods  familiar  to  electricians,  that  the  free  ends  of 
both  plates  are  charged  with  electricity.  If  the  free  ends  of  the 
plates  be  conjoined  by  means  of  a  copper  wire  the  plates  imme- 
diately deliver  their  charges  through  the  wire.  But  since  the  chemi- 
cal action  now  becomes  continuous  the  charge  is  continuously  re- 
newed, and  thus  a  constant  flow  of  electrical  disturbance  is  main- 
tained. If  the  wire  be  disconnected,  the  chemical  action  ceases  in 
the  cell,  and  the  flow  of  electricity  is  arrested.  Both  are  renewed 
on  again  connecting  the  plates.  The  active  metal,  zinc,  is  called 
the  yodtive  element  of  the  cell,  the  carbon  the  negative  element. 
The  conjunctive  wire,  the  plates,  and  the  intervening  cohinm  of 
fluid  constitute  the  electrical  circuit.  The  continuous  propagation 
of  the  molecular  disturbance  in  the  circuit  gives  rise  to  the  teim 
current.  For  convenience,  the  current  through  the  wire  is  said  to 
flow  from  the  carbon  to  the  zinc  plate,  though  in  fact  we  have  two 
currents,  one  of  positive  electricity  flowing  from  carbon  to  zinc,  and 
one  of  negative  electricity  from  zinc  to  carbon.  The  free  end  of 
the  carbon,  from,  which  electricity  flows  through  the  wire,  is  termed 
the  positive  j)ole.,  the  corresponding  end  of  the  zinc  is  the  negative 
pole  of  the  cell.  If  the  conjunctive  wire  be  cut,  the  free  ends  of  the 
wire  now  become  the  poles  of  the  circuit,  one  the  positive,  the  other 


368  DISEASES  OF   WOMEN. 

the  negative  j)ole.  For  ordinary  therapeutic  uses  metallic  ])late8 
variously  covered  with  moist  sponge,  chamois,  or  otherwise,  are  at- 
tached to  the  free  ends  of  the  wire,  and  are  commonly  termed 
electrodes  (from  eXeKrpov  and  0809,  the  electrical  pathway).  The 
positive  electrode,  sometimes  called  the  anode  {ava  and  oBo^,  the  way 
up),  the  negative  electrode,  the  cathode  (Kara  and  0809,  the  way 
down).  A  combination  of  several  galvanic  cells  in  a  common  cir- 
cuit is  a  galvanic  hath nj. 

Bodies  which,  like  the  conjunctive  wire,  are  capable  of  transmit- 
ting electricity,  arc  called  conductors.  Others  which  lack  this  prop- 
erty are  termed  non-conductors.  These  terms,  however,  are  merely 
relative.  Different  substances  differ  widely  in  their  conducting  power, 
and,  strictly  speaking,  no  body  is  so  good  a  conductor  as  to  oppose 
no  resistance  to  the  passage  of  the  current,  none  so  poor  a  conductor 
that  its  resistance  may  not  be  overcome  in  some  measure  by  power- 
ful currents.  The  metals  are  examples  of  good  conductors,  silver 
and  copper  being  the  best.  Glass,  vulcanite,  ivory  or  bone,  and  dry 
wood  ai*e  good  non-conductors.  Such  substances,  when  used  for  the 
purpose  of  preventing  leakage  of  the  current,  as  in  the  handles  of 
electrical  instruments,  are  termed  insulators. 

The  capacity  of  a  galvanic  cell  for  generating  electricity  is  de- 
nominated its  electro-motive  force.  It  depends  upon  the  energy  of 
the  chemical  action  in  the  cell,  and  therefore  varies  with  the  ma- 
terials which  enter  into  its  construction.  In  a  battery  of  similar 
cells  arranged  in  series  (the  zinc  of  one  cell  being  connected  with 
the  carbon  of  its  neighbor),  the  electro- motive  force  will  be  increased 
in  proportion  to  the  number  of  cells. 

The  term  current  is  not  only  applied  to  the  flow  of  electricity  in 
the  circuit  but  is  also  used  in  a  quantitative  sense.  It  is  employed 
ill  the  sense  of  current  strength,  and  represents  the  quantity  of  elec- 
tricity flowing  through  the  circuit.  The  term  resistance  is  used  to 
denote  the  degree  of  obstruction  opposed  by  the  circuit  to  the  pas- 
sage of  electricity  through  it.  As  may  be  inferred  from  what  has 
already  been  said  ^A\\\  reference  to  the  conducting  power  of  bodies, 
resistance  varies  with  the  materials  of  which  the  circuit  is  conq)osed. 
In  case  of  wire,  or  other  conductor  of  given  material,  the  resistance 
varies  directly  as  its  length,  and  inversely  as  its  sectional  area.  Not 
only  the  conjunctive  wire,  but  the  exciting  fluid  as  well,  and  the 
plates  of  the  cell  offer  a  greater  or  less  amount  of  resistance.  The 
total  resistance  within  the  cell  is  designated  the  internal,  in  distinction 
from  that  without,  which  is  called  the  external  resistance  of  the  circuit. 
The  electro-motive  force  of  a  battery  corresponds  approximately 


FIBROMA.  OF  THE   UTEFvUS.  369 

to  the  liorse-power  of  a  steam-engine,  the  current  to  the  motion  of  tlie 
machinery.  The  vahic  of  the  current  in  a  given  circuit  will  depend 
not  only  on  the  electro-motive  force  of  the  battery,  but  also  upon  the 
resistance  in  the  circuit.  It  will  vary  directly  as  the  electro-motive 
force,  and  inversely  as  the  resistance.  In  other  words,  the  current  will 
he  equal  to  the  electro-motive  force  divided  by  the  resistance.  This 
is  the  law  of  currents,  and  is  known  as  Ohm's  law,  so  named  from  its 
discoverer.  Letting  C  stand  for  current,  E  for  electro-motive  force, 
and  R  for  resistance,  the  law  may  be  conveniently  expressed  by  the 

E 

R 


following  formula,  C  =  .^  .     Putting  R'  for  the  internal  resistance, 


E 

and  W  for  the  external,  we  have  C  =  ^^j-, ^f^, .    By  application  of  sim- 

Iv    +  iw 

pie  algebraic  rules,  any  three  of  these  quantities  being  known,  the 
other  may  be  found.  A  knowledge  of  this  law  and  its  uses  is  of  the 
utmost  importance  in  all  practical  applications  of  electricity.  By  its 
aid  many  of  the  perplexing  problems  encountered  by  the  beginner 
in  electrical  practice  may  be  readily  solved. 

For  quantitative  determinations  we  must  have  units  of  quantity. 
The  adopted  unit  of  electro  motive  force  is  the  volt,  that  of  resist- 
ance the  o/wi,  and  that  of  current  the  amjpere.  A  volt  is  the  amount 
of  electro-motive  force  necessary  to  yield  one  ampere  of  current 
through  one  ohm  of  resistance.  An  ohm  represents  approximately 
the  resistance  offered  by  230  feet  of  pure  copper  wire  of  No.  16 
American  wire  gauge.  A  volt  is  very  nearly  the  electro-motive 
force  of  a  single  Daniell's  cell. 

To  illustrate  the  application  of  Ohm's  law  in  practice,  suppose 

the  electro-motive  force  of  a  given  galvanic  cell  to  be  1*5  volts.    Let 

the  internal  resistance  be  one  ohm,  and  that  of  the  connecting  wire 

E  1'5 

•5  ohm.     We  have  C  =  -or-r^oA^  =  7-^=1-     One  ampere  is  then 

I\  -[-  K        I'o 

the  strength  of  current  that  flows  in  such  a  circuit.  If,  now,  we 
have  a  battery  of  fifty  such  cells,  connected  in  series,  the  total  elec- 
tro-motive force  of  the  battery  will  be  75  volts,  and  the  total  internal 
resistance  will  be  50  ohms.  Suppose  that  a  portion  of  the  human 
body  and  the  necessary  instruments  for  regulating,  measuring,  and 
applying  the  current  be  introduced  into  the  external  portion  of  the 
circuit.  If  the  tissues  of  the  body  in  the  circuit  offer  a  resistance 
of  1,000  ohms  and  the  instruments  and  conducting  wire  a  total  of 
4.50  ohms,  the  entire  external  resistance  will  be  1,450  ohms.     From 

T5 
Ohm's  formula  we  have  - — ,   ,  ,^    =  "050.      The   current   in    this 
25  50  +  1,450 


370  DISEASES   OF   WOMEN. 

case  will  therefore  be  fifty  tliouRandtliR  of  an  ampere,  or,  as  it  is  ex- 
pressed, 50  milliamperes,  tlie  milliaiiipere  being  one  thousandth  of  ;ni 
ampere. 

From  C  =  ^,  f  ^.„  we  get  R'+  R"  =  ?  and  R"  =  ?  -  R'. 

Tlie  required  data  being  given,  we  may  by  means  of  this  formula 
find  the  total  external  resistance  or  any  component  part  of  it.  Sup- 
pose a  portion  of  the  body  be  connected  in  circuit  with  the  same 
battery,  instniments  and  conducting  wires  as  in  the  case  last  cited. 
Suppose  the  current  is  now  found  to  be  50  milliamperes.  The 
resistance,  exclusive  of  that  offered  by  the  tissues  interposed,  being 
known,  we  may  readily  compute  the  resistance  of  the  portion  of  the 
body  through  which  the  current  is  passed.     We  have  frt»m  the  last 

formula,  R"  =  5  -  R',  R"  =  ^^J"  -  50  =  1,450.     Deducting  the 

vy  *U0' ' 

known  resistance  of  the  wire  and  instruments,  we  have  1,450  —  450 
=  1,000.  The  resistance  offered,  then,  by  the  portion  of  the  body 
placed  between  the  electrodes  is  1,000  ohms. 

From  the   formula   C  =  -^,      -^„  we  also  have  R'  =  — -  —  11' 

K  -|-  K  C 

and  E  =  C  (R'  -f-  K").    The  application  of  these  formulas  in  practice 

is  obvious  from  the  illustrations  already  given. 

When  enormous  resistances  like  those  of  the  human  body  are  con- 
cerned, such  elements  in  the  computation  as  the  internal  resistance  of 
the  battery,  if  it  be  low,  and  that  of  the  conducting  wires  may  be  disre- 
garded.    The  results  will  be  sufficiently  exact  for  practical  purposes. 

The  resistance  offered  by  the  human  body  is  by  no  means  a  con- 
stant quantity.  It  varies  by  hundreds  of  ohms  not  only  with  the 
amount  of  tissues  interposed  in  the  circuit,  but  also  \\dth  the  varying 
character  of  the  tissues  in  different  parts  of  the  body,  the  area  of  the 
electrodes  and  their  firmness  of  contact,  with  the  degree  of  moisture 
of  the  part  to  which  they  are  applied,  and  other  causes.  It  is  well 
known  that  the  conducting  power  of  the  electrodes  and  the  com- 
pleteness of  the  electrical  contact  may  be  increased  by  moistening 
the  electrodes  with  a  saline  or  acid  solution,  instead  of  plain  water, 
a  fact  often  useful  in  practice. 

The  accumulation  of  hydrogen  bubbles  which  takes  place  ujion, 
the  surface  of  the  carbon  plate  when  the  battery  is  in  action  weakens 
the  current  in  proportion  to  the  extent  of  surface  so  covered.  This 
phenomenon  is  known  as  polarization.  Various  means  are  provided 
in  the  construction  of  different  batteries  for  overcoming  this  diflR- 
culty,  or,  as  the  expression  is,  for  depolarizing.     For  example,  di 


FIBROMA   OF  THE  UTERUS.  371 

polarization  is  accomplished  in  certain  cautery  batteries  by  occasion- 
ally agitating  the  fluid  and  thus  removing  the  hydrogen  from  the 
plate.  In  ordinary  batteries  the  effects  of  polarization  are  partially 
or  wholly  obviated  by  various  chemical  provisions. 

Ey  electrolysis  [eXe/crpov  and  \vai<;)  is  meant  electro-decompo- 
sition, or  the  resolution  of  the  chemical  compound  into  two  con- 
stituent parts  by  the  action  of  the  current.  For  a  simple  illustration 
of  electrolysis,  place  in  a  beaker-glass  a  solution  of  iodide  of  potas- 
sium. Selecting  for  the  electrodes  some  non-corrodible  metal,  plat- 
inum-wire for  example,  innnerse  them  at  a  short  distance  apart  in 
the  solution.  Iodine  will  be  liberated  at  the  positive  pole  and  potas- 
sium at  the  negative.  A  few  drops  of  starch- water  dropped  into  the 
solution  will  demonstrate  the  presence  of  free  iodine  at  the  positive 
electrode,  and,  since  the  potassium  enters  into  combination  with 
oxygen  and  hydrogen,  forming  the  hydrate  of  potassium,  an  alkali, 
its  presence  may  be  shown  at  the  negative  pole  by  a  few  drops  of 
red-litmus  sohition.  The  body  thus  decomposed  is  termed  an  electro- 
lyte. Since  bodies  which  are — in  an  electrical  sense — unlike,  attract 
one  another,  and  like  bodies  repel,  chemical  elements  attracted  to 
the  positive  pole  are  called  electro-negative  elements,  those  which  go 
to  the  negative  pole  electro-positive  elements.  In  general,  substances 
liberated  at  the  negative  pole  are  termed  anions^  those  set  fi'ee  at 
the  positive  pole,  cations. 

Galvanic  currents,  with  which  we  have  thus  far  dealt,  are  con- 
tinuous currents.  The  current  of  a  faradic  machine  is  an  interrupted 
current,  consisting  of  a  series  of  more  or  less  rapidly  recurring  im- 
pulses. Moreover,  it  is  an  alternating  current — that  is  to  say,  each 
alteraate  impulse  traverses  the  circuit  in  opposite  directions.  Since 
the  polarity  is  reversed  with  each  impulse  there  is  no  difference  in 
the  therapeutic  action  of  the  electrodes.  The  electricity  of  a  static 
machine  is  also  characterized  by  instantaneous  discharges.  Another 
important  difference  between  faradic,  or  especially  static  and  gal- 
vanic electricity,  is  one  of  tension.  By  tension  or  potential  is  un- 
derstood power  to  overcome  resistance  in  the  circuit.  Faradic,  and 
especially  static  electricity,  are  characterized  by  high  tension.  The 
value  of  the  electric  current,  other  things  being  equal,  depends 
upon  the  difference  of  potential  between  the  point  from  which  and 
that  to  which  the  current  flows,  just  as  the  force  of  a  waterfall  de- 
pends upon  the  difference  of  water-level  above  and  below  the  fall. 

Space  will  not  permit  a  description  or  even  an  enumeration  of 
the  various  forms  of  the  galvanic  cell,  which  are  more  or  less  suited 
to  therapeutic  requirements.     For  portability  the  latest  forms  of 


372 


DISEASES  OF   WOMEN. 


the  chloride  of  silver  hattery  leave  little  or  nothing  to  he  desired. 
Their  principal  disadvantage  is  a  high  and  varying  internal  resist- 
ance. They  answer  well,  however,  the  ordinary  requirements  of 
galvanization.  For  a  stationary  battery  for  office  use  the  Leclanche 
battery,  or  more  especially  some  one  of  its  nioditications,  is  deservedly 
becoming  ])opular.  Any  amount  of  electro-motive  force  required 
by  the  physician  for  galvanization  or  electrolysis  may  be  obtained 
by  the  use  of  a  large  number  of  cells,  and  for  cleanliness,  con- 
venience, and  durability  they  are  thus  far  unexcelled.  A  battery 
of  forty  to  'Sixty  such  cells,  though  somewhat  cumbersome,  can 
easily  be  disposed  of  in  a  closet  or  in  the  cellar.  With  proper 
use  it  is  always  ready  for  work,  and  requires  little  or  no  attention 

for  long  periods.  The  best 
modification  of  the  Leclanche 
battery  that  has  been  brought 
to  our  notice  is  the  Law  bat- 
tery (Fig.  ISO).  Its  mechan- 
ical construction  is  of  the  ; 
highest  order.  It  is  subject 
to  absolutely  no  deterioi-ation 
when  not  in  use — which  can 
not  be  said  of  most  batteries, 
even  of  the  Leclanche  par- 
tern.  The  carbon  plate  is 
jirepared  by  a  sjiecial  process, 
and,  with  projier  care,  lasts 
indefinitely.  The  only  part> 
that  require  renewal  are  the 
zinc  and  the  exciting  fluid,  ! 
and  these  Imt  once  in  two  or  • 
This  is  an  inqiortant  advantage 
over  other  forms  of  the  Leclanche  cell  in  which  the  carbons  as  well 
as  the  other  elements  require  renewal,  from  time  to  time,  at  an  ex- 
pense little  short  of  the  first  cost  of  the  cell. 

For  cautery  purposes,  it  is  not  unlikely  that  a  small  ])ortable  bat- 
tery of  storage  cells  will  be  found  most  suitable.  They  can  be 
readily  recharged  during  the  intervals  of  use  by  means  of  a  few 
gravity  cells.  The  well-known  cautery  batteries  of  Pilfard,  Daw- 
son, and  Byrne  are  extensively  employed,  but  are  inferior  to  a  good  j 
storage  battery  in  reliability  and  in  convenience  of  use. 

There  is  a  common  misapprehension  in  regard  to  the  effect  of 
the  size  of  cells  upon  the  current.     The  electro-motive  force  of  o 


Fig.  180. — Law  cell. 


three  years  in  ordinary  office  use. 


FIBROMA   OF  THE   UTERUS.  373 

cell  of  given  elements  renitains  the  same  whether  the  size  be  large  or 
small.  The  internal  resistance  of  the  large  cell  is  less  than  that  of 
the  small  one  since  the  resistance  of  the  column  of  fluid  between 
the  plates  varies  inversely  as  its  sectional  area.  Through  a  low  ex- 
ternal resistance  large  cells  will  give  more  current  than  small  ones. 
If  the  external  resistance  be  very  great  the  current  will  be  practically 
the  same  whatever  the  size  of  the  cells.  This  may  be  shown  by 
Ohm's  law.  With  a  battery  of  fifty  cells,  each  having  an  electro- 
motive force  of  1'5  volt  and  an  internal  resistance  of  1  ohm,  let  the 

E  75 

external  resistance  be  10  ohms.     We  have  C  =  -f^Tn^UT/  =  ^~r — \~^rr^ 

it  -(-XV         50  -f-  10 

=  1*25.     A  battery  cell  with  plates  five  times  as  large  will  have  one 

fifth  the  internal  resistance,  or  '2  ohm.     The  current  from  fifty  such 

75 
cells  through  the  same  resistance  will  be  =  3'75.     Thus 

there  is  a  great  gain  in  the  use  of  large  cells  when  the  external  re- 
sistance is  small,  as  is  the  case  in  cautery  batteries.  Not  so  in  case  the 
current  is  passed  through  great  resistances  like  those  of  the  human 
body.     Suppose,  for  example,  the  external  resistance  is  1,450  ohms. 

75 
With   the   battery  of  fifty  small   cells  we  have  C  =  — — ; — ^   .^^ 
'^  -^  50  -j-  IjioO 

=  -050.    With  the  battery  of  fifty  large  cells  of  the  same  material  C  = 

75 

:; =  -051-1-.     There  is  practically  no  gain  in  the  strength 

10  4- 1,450  ^  F  .;        &  & 

of  cun'ent.  The  only  advantage  of  the  large  cells  for  the  purpose  of 
electrolysis  or  galvanization  is  the  greater  amount  of  materials  and 
consequently  greater  durability. 

In  cautery  batteries,  however,  the  resistances  are  comparatively 
small,  and  here  large  cells  are  used.  Moreover,  only  a  small  num- 
ber of  cells  is  required.  If  it  were  possible  to  construct  a  circuit 
having  no  external  resistance  one  cell  would  give  as  much  current 
as  a  thousand.     With  a  cell  having  an  electro-motive  force  of  1*5 

1'5 
volt  and  an  internal  resistance  of  '2  we  have  C  =  =  7*5  ; 

with  a  thousand  such  cells  we  have  C  =      '  =  7"5.    It  will  be 

^00  — (—  0 

readily  seen  that  where  very  low  external  resistances  are  concerned 
very  little  gain  in  cuiTent  will  be  effected  by  multiplying  the  num- 
ber of  cells.  As  the  external  resistance  increases  a  larger  number  of 
cells  will  be  required,  hence  the  large  number  of  cells  needed  when 
the  enormous  resistances  of  the  human  body  are  to  be  overcome. 
Exact  dosage  is  no  less  important  in  electricity  than  in  the  use  of 


374 


DISEASES   OF    WOMEN. 


Fig.  181. — Milliamp^remeter. 


other  reined iiil  agents.  The  old  metliod 
of  meusuriiig  the  current  hy  tlie  niuuber 
of  cells  employed  was  entirely  wanting 
in  precision.  Owing  to  the  gradual  ex- 
haustion of  the  hattery-Huid  by  use,  the 
varying  resistance  of  the  conducting- 
cords,  the  electrodes,  and  the  diifeivnt 
portions  of  the  body,  there  can  Ix;  no 
constant  relation  between  the  number  of 
cells  in  circuit  and  the  current  strength. 
A  convenient  and  reliable  galvanc^meter 
is,  therefore,  to  the  electro-therapeutist 
what  the  apothecary's  balance  or  graduate 
is  to  the  dispenser  of  drugs.  The  vertical  galvanometer  will  be 
found  the  best  for  the  purpose,  and 
it  should  cover  a  range  of  from 
one  to  five  hundred  milliamperes. 
The  milliamperemeter  of  Barrett 
and  Perret  has  proved  a  satisfacto- 
ry galvanometer  in  our  use  (Fig. 
181). 

For  the  purpose  of  regulating 
the  current  strength  a  current  se- 
lector or  switch-board,  by  means  of 
which  a  large  or  small  number  of 
cells  can  be  switched  into  circuit, 
has  been  commonly  employed.  This 
device  is  open  to  the  objection  that 
it  uses  different  portions  of  the  bat- 
tery unequally ;  that  it  does  not 
permit  a  sufficiently  gradual  in- 
crease or  decrease  of  the  current ; 
and  that,  as  the  switch  jumps  from 
one  stud  to  the  next,  at  the  instant 
when  it  touches  both,  one  cell  is 
short-circuited  and  its  force  thus 
wasted.  Instead  of  the  switch-board 
I  have  used,  for  some  time,  a 
rheostat  or  cuiTent  -  regulator,  in- 
vented l)y  Mr.  II.  S.  Bailey,  elec- 
trician of  the  Law  Telephone  Com- 
pany,   of    New    York    (Fig.    182).  Fiq.  182.— Rheostat. 


FIBROMA  OF  THE   UTERUS.  375 

This  instrument  consists  of  a  hundlc  of  carbon  plates  insulated  from 
one  another,  placed  in  vertical  j)osition,  and  attached  to  a  vertical  me- 
tallic rod,  by  means  of  which  it  can  be  racked  up  and  down  in  a  col- 
uam  of  water.  "When  connected  in  circuit,  the  strength  of  current 
is  regulated  by  the  depth  of  immersion  as  in  the  common  water- 
rheostat,  but  with  the  advantage  over  that  instrument  of  much  greater 
precision  and  greater  facility  of  manipulation.  By  means  of  this 
rheostat  a  resistance  of  from  twenty  to  two  million  ohms  can  be 
thrown  into  circuit.  The  current  can  thus  be  gauged  at  will  from 
an  imperceptible  strength  of  one  or  two  milliamperes  to  the  full 
force  of  the  battery.  The  current  may  be  increased,  diminished,  or 
turned  oft"  altogether,  without  the  slightest  shock  to  the  j^atient,  an 
important  advantage  over  the  switch-board.  This  method  of  regu- 
lating the  current  has  the  advantage,  too,  of  using  the  entire  battery 
at  once,  whether  the  current  applied  be  one  or  a  thousand  milliam- 
peres. Since  each  cell  does  the  same  amount  of  work  as  its  neighbor 
all  parts  of  the  battery  constantl^^  maintain  an  equable  strength. 
Moreover,  the  comparatively  trifling  cost  of  the  regulator  is  a  by  no 
means  unimportant  item.  The  introduction  of  the  Bailey  regulator 
and  the  railliamperemeter  marks  an  important  advance  in  electro- 
therapy. 

The  Method  of  applying  the  Electric  Current  in  the  Treatment  of 
Fibroid  Tumors. — The  method  of  using  the  current  which  I  have 
adopted,  is  to  pass  an  electrode  into  the  cavity  of  the  uterus,  and  in- 
sulate that  portion  of  the  instrument  which  rests  in  the  vagina.  The 
other  electrode — a  broad  one — is  applied  over  the  abdominal  surface 
where  the  tumor  is  located.  The  electrode  in  the  uterus  is  connected 
with  the  negative  pole  of  the  battery,  and  the  other  with  the  positive. 
The  current  then  is  gradually  turned  on,  until  it  is  as  strong  as  the 
patient  can  tolerate  it,  and  is  continued  for  eight  or  ten  minutes. 
This  is  repeated  every  third  or  fourth  day.  The  electrode  which  is 
introduced  into  the  uterus  is  shaped  like  a  uterine  sound.  The  por- 
tion of  it  which  occupies  the  cavity  of  the  uterus  is  made  of  plati- 
num. The  rest  is  copper  covered  with  hard  rubber,  and  over  this 
there  is  a  sheath  of  rubber,  which  can  be  moved  forward  or  back- 
ward to  regulate  the  length  of  the  portion  to  be  insulated,  which 
varies,  according  to  the  depth  of  the  canal  of  the  uterus  in  different 
cases. 

Fig.  183  shows  this  instrument.  The  electrode  which  Apostoli 
uses  for  the  outside  of  the  tumor  is  composed  of  sculptor's  clay, 
rolled,  cut  to  a  size  sufficient  to  cover  the  prominent  part  of  the 
tumor,  and  about  half  or  three  quarters  of  an  inch  thick.     The  chy 


37G  DISEASES  OF  WOMEN. 

is  covered   with  some  tliiu  fabric  like  cLeese-clotli,  to  keep  it  to- 
getlier.     This  is  applied  over  the  abdomen,  and  then  a  broad  me- 

^ 


Fig.  183. — Uteriiiu  flcctiudL-. 


tallic  plate  applied  over  the  clay.  This  answers  very  well  so  far  as 
fitting  the  rounded  abdominal  surface,  and  by  its  own  weight  it 
keeps  its  place  with  and  also  protects  the  skin  from  irritation.  It  is 
not  very  convenient,  however.  The  clay  has  to  be  kept  wet  all  the 
time,  in  order  to  be  ready  for  use  when  required.  It  also  requires 
to  be  made  warm  in  cold  weather,  and  is  not  very  clean  to  handle. 
Owing  to  these  inconveniences  of  the  clay,  other  materials  have 
been  used.  I  employ  a  sheet  of  absorbent  cotton  about  balf  an  inch 
thick  when  wet,  and  gently  compressed,  and  over  that  an  electrode 
made  of  a  number  of  small  metallic  plates  fastened  together  with 
Avire.  In  this  way  the  electrode  fits  the  irregular  curves  of  the  ab- 
dominal walls.  Even  this  is  not  exactly  what  I  desire.  AVhile  it  is 
free  from  the  objections  of  the  clay  it  does  not  adapt  itself  to  the 
body  as  well  as  the  clay.  This  leads  me  to  believe  that  something 
more  convenient  than  anything  now  in  use  may  be  yet  devised. 

This  gives  the  method  of  using  electrolysis  in  the  way  which 
appears  to  me  to  be  most  acceptable,  but  there  are  modifications  as 
practiced  by  some  which  should  be  noticed. 

Some  prefer  to  ansesthetize  the  patient  and  use  a  current  stronger 
than  the  patient  could  otherwise  bear.  This  may  insure  more  rapid 
progress  in  the  treatment,  but  it  is  perhaps  more  dangerous  and 
disagreeable  to  the  patient.  I  prefer  a  current  which  the  patient 
can  tolerate,  and  continue  it  longer  at  a  time  and  repeat  the  treat- 
ment more  times. 

Sometimes  it  happens  that  the  cervix  uteri  is  displaced,  so  that 
the  electrode  can  not  be  introduced  into  the  uterine  cavity.  In  such 
cases,  a  needle-pointed  electrode  should  be  thrust  into  the  tumor,  and 
the  curi'ent  passed  in  the  usual  way.  Apostoli  speaks  of  this  as 
making  an  artificial  canal  in  place  of  the  normal  one  of  the  uterus. 

In  order  to  maintain  this  canal  made  by  the  first  puncture,  the 
current  used  must  be  strong  enough  to  destroy  the  tissues  in  imme- 
diate contact  with  the  instrument.  Should  the  opening  close  another 
puncture  can  be  made  at  the  next  treatment. 

In  cases  where  there  is  severe  monorrhagia  Apostoli  recommends 
the  introduction  of  the  positive  electrode  into  the  uterus,  and  using 
a  current  strong  enough  to  slightly  char  or  dry  the  mucous  mem- 


FIBROMA    OF  THE   DTERCS.  377 

brane,  and  in  that  way  arrest  tlie  bleeding.  This  is  no  doubt  good 
practice  when  the  l^leeding  can  not  be  arrested  by  other  means  such 
as  curetting  or  the  application  of  astringents. 

(illustrative  oases.) 

Fibroma  of  the  Uterus ;  Recovery  without  Treatment. — This  case 
illustrates  a  class,  not  by  any  means  large,  in  which  the  disease 
runs  its  course  without  causing  much  discomfort  or  impaii'ing  the 
health  to  any  great  extent,  and  without  being  influenced  by  treat- 
ment. The  patient  was  highly  nervous  and  very  active,  had  a  good 
constitution,  and  enjoyed  good  health.  When  she  was  about  thirty 
years  old  her  menstrual  flow  became  more  free  than  formerly.  She 
had  up  to  that  time  been  quite  regular  and  normal  in  regard  to  men- 
struation. This  slight  menorrhagia  continued,  and  occasionally  was 
quite  profuse.  She  also  had  backache  and  pelvic  tenesmus,  which 
rendered  her  less  active  and  enduring  than  in  her  earlier  life,  I 
first  saw  her  professionally  when  she  was  thirty-one  years  of  age. 
She  was  then  single  and  enjoying  fair  health.  I  supposed  that  she 
might  have  a  fibroma  of  the  uterus  from  the  history,  and  suggested 
that  I  should  find  out  by  examination  the  exact  condition.  This  she 
objected  to. 

From  this  onward  she  continued  about  the  same.  The  menor- 
rhagia continued,  and  she  had  at  times  dysmenorrhoea  and  leucor- 
rhoea,  but  all  of  these  did  not  impair  her  health  or  usefulness  suf- 
ficiently to  make  her  willing  to  submit  to  treatment.  At  forty 
years  of  age  she  married,  and  then  her  symptoms  increased  consid- 
erably, but  in  the  intermenstrual  periods  she  was  fairly  well.  Four 
years  after  her  marriage  she  had  an  attack  of  malarial  fever  of  a  mild 
order,  and  then  the  menorrhagia  and  dysmenorrhoea  became  worse, 
and  I  then  had  an  opportunity  to  examine  her,  and  found  that  there 
was  a  fibroma  in  the  posterior  wall  of  the  uterus,  probably  inter- 
stitial. She  soon  recovered  from  the  malaria  and  its  effects,  and 
then  her  uterine  troubles  became  as  they  had  been  formerly.  About 
this  time  I  made  an  application  of  iodine  to  the  cavity  of  the  uterus, 
but  as  she  improved  she  did  not  return  for  further  treatment.  I 
saw  her  occasionally  while  visiting  other  members  of  her  family,  and 
heard  that  she  was  about  the  same  as  formerly. 

According  to  her  own  statement,  she  was  not  at  any  time  quite 
well,  but  not  ill  enough  to  be  willing  to  be  treated.  When  she  was 
forty-nine  she  again  consulted  me,  and  I  then  found  that  the  men- 
strual flow  had  been  diminished  for  over  one  year,  and  had  been  ab- 
sent altogether  for  three  months.     She  was  quite  nervous  and  rest- 


378  DISEASES   OF   WOMEN. 

less,  just  as  many  are  at  tlie  int'ii<t])ause.  I  examined  tlie  uterus, 
and  found  that  the  iibronia  liail  almost  disappeared.  TIil'  uterus 
was  much  hirger,  at  least  twice  as  laroje  as  it  should  be  after  the 
menopause,  but  not  one  third  the  size  that  it  was  when  I  first  ex- 
amined the  case.  I  have  seen  her  since,  and  find  that  she  is  (juite 
well. 

Interstitial  Fibroma  of  Large  Size,  complicated  with  Endometritis; 
treated  by  Tincture  of  Iodine  to  the  Endometrium,  Ergot  during  the 
Menstrual  Period,  and  Mild  Continuous  Current  of  Electricity. — -A 
stront>-  and  vigorous  lady  wlio  liad  always  enjoyed  gcjod  health  until 
after  she  was  twenty-five  years  old,  Avas  fii'st  seen  when  she  was 
thirty-one.  She  M'as  married  at  twenty-six,  and  soon  thereafter 
began  to  menstruate  too  freely ;  she  never  was  pregnant.  AYhen 
first  seen  she  was  prostrated  with  a  severe  menorrhagia.  1  then  ob- 
tained tlie  facts  given  above,  and  also  learned  that  she  had  suffered 
from  pelvic  pain,  leucorrhcea,  backache,  and  a  gradually  increasing 
menstrual  flow  until  the  time  I  saw  her,  when  she  was  quite  ex- 
hausted. Tbe  uterus  and  tumor  extended  upward  to  half-way  be- 
tween the  pubes  and  umbilicus.  Stimulants  and  ergot  were  given, 
but  the  How  continued,  and  then  the  tampon  was  used,  which  stopped 
it.  She  improved  from  this  time,  quite  perceptibly,  but  was  pulled 
down  at  the  next  period,  thougli  not  to  so  low  a  point  as  before.  She 
was  then  put  under  treatment  for  the  endometritis.  The  hot- water 
douche  was  tried,  and  the  whole  endometrium  touched  with  tincture 
of  iodine.  In  order  to  do  this  it  was  necessary  to  dilate  the  os  exter- 
num, and  then  by  using  the  pipette,  the  application  could  be  made 
very  thoroughly.  There  was  at  first  considerable  catarrh  of  the  cer- 
vix, and  for  that  a  few  applications  of  tincture  of  iodine  and  carbolic 
acid,  equal  parts,  were  made.  Under  this  treatment  the  menstrual 
flow  became  less  free,  althougli  the  tumor  increased  slightly  in  size. 
After  remaining  under  treatment  intermittently  for  about  two  years, 
she  was  induced  to  place  herself  under  the  care  of  a  physician  who 
made  the  acquaintance  of  her  husband.  Tiiis  gentleman  treated  her 
twice  a  week  with  a  mild  continuous  current  of  electricity,  which  he 
passed  through  the  tumor  by  placing  one  electrode  upon  the  ab- 
domen and  the  other  upon  the  back. 

Three  quarters  of  a  year  were  occupied  in  this  way,  but  without 
any  improvement ;  she  neither  gained  nor  lost,  except  that  her  flow 
was  more  free.  She  returned  to  my  care  again,  and  I  resumed  the 
treatment  of  the  endometritis  with  iodine;  I  also  continued  the  elec- 
tricity, but  did  so  by  procuring  a  battery  for  the  patient,  and  having 
one  of  my  assistants  teach  her  how  to  use  it.     In  place  of  applying 


FIBROMA   OF   THE   UTERUS.  379 

it  twice  a  week,  as  the  doctor  had  done,  she  used  it  every  day,  and  I 
am  satisfied  that  she  nsed  it  as  effectually  as  the  doctor. 

This  treatment  was  kept  up  for  two  years.  Whenever  her  menses 
became  very  free,  or  if  the  lencorrhfca  returned,  she  came  for  treat- 
ment, otherwise  she  used  the  electricity  alone.  The  tumor  had 
diminished  perceptibly,  but  her  general  improvement  was  out  of 
proportion  to  local  changes,  excepting  that  the  endometritis  was  re- 
lieved. After  this  she  went  to  live  in  the  country,  and  was  not  seen 
again  until  she  was  forty-six  years  old.  I  then  found  that  the 
menses  were  normal,  and  that  the  tumor  was  very  much  reduced. 
When  first  seen,  I  could  with  ease  introduce  the  sound  into  the 
uterus  seven  and  a  half  inches,  while  at  the  age  of  forty-six  the 
cavity  of  the  uterus  measured  less  than  four  inches. 

Interstitial  Fibroma  of  the  Uterus  treated  with  Ergot ;  Recovery. 
— This  patient  was  thirty-four  years  old,  married,  and  had  one  child 
when  she  was  twenty-three  years  old.  After  its  birth  she  suffered 
from  leucorrhoea  and  backache,  but  did  not  have  any  treatment  until 
she  was  twenty-seven  years  of  age.  She  then  began  to  menstruate 
too  freely,  and  was  treated  by  her  physician,  but  without  effect. 
The  menorrhagia,  while  it  depressed  her,  did  not  disable  her  alto- 
gether, so  she  went  about  her  duties  nntil  she  noticed  a  tumor  in  tlie 
abdomen  ;  she  then  came  to  me  for  advice.  I  found  the  uterus  en- 
larged, extending  upward  to  within  two  inches  of  the  umbilicus. 
The  cavity  of  the  uterus  was  deflected  to  the  right  and  backward, 
and  the  sound  passed  to  the  depth  of  seven  inches.  The  fibroma 
occupied  the  left  anterior  wall  and  projected  considerably  to  the 
left,  giving  to  the  whole  mass  (uterus  and  tumor)  an  irregular  out- 
line. 

There  was  some  endometritis,  and  the  patient  was  slightly  ange- 
mic,  but  otherwise  her  health  was  good.  Half  a  drachm  of  fluid 
extract  of  ergot  was  given  before  meals,  for  about  a  month,  in  the 
hope  that  it  might  incline  the  tumor  toward  the  cavity  of  the 
uterus,  and  by  partially  expelling  it  bring  it  within  reach  for  the 
operation  of  enucleation.  At  the  end  of  a  month  there  was  no 
change  in  the  position  of  the  tumor ;  ergot  was  then  used  hypoder- 
mically  about  twenty  minims  every  third  day.  This  excited  strong 
uterine  contractions,  which  lasted  for  about  an  hour  or  more  each 
time.  This  treatment  was  continued  for  three  weeks,  but  without 
changing  the  position  of  the  tumor,  though  it  diminished  in  size. 
The  hypodermic  use  of  the  ergot  was  then  given  up,  because  the 
patient  became  tired  of  the  pain  it  caused.  She  continued  to  take 
the  quantity  first  given  by  the  mouth  for  seven  or  eight  weeks,  and 


380  DISEASES  OF   WOMEN. 

the  tumor  continued  to  decrestse  in  size.  TIjc  liypoderniic  use  of  the 
ergot  was  tried  a<i:ain  f(jr  nearly  a  month,  but  was  only  used  every 
fourth  day.  At  tlie  end  of  three  months  all  treatment  was  stopped 
because  the  patient's  digestion  became  impaired.  She  was  kept 
upon  tonic  treatment  for  a  time  until  her  general  condition  imjjroved, 
and  again  the  ergot  was  resumed,  using  it  hypodermically  and  by 
the  mouth  alternately.  The  menorrhagia  gradually  subsided,  and  at 
the  end  of  six  months  the  tumor  had  diminished  over  two  thirds  of 
its  former  size.  The  cavity  of  the  uterus  was  only  three  and  three 
quarter  inches  in  depth.  No  further  treatment  wa.s  deemed  neces- 
sary. Three  years  after  the  treatment  was  suspended  the  patient 
was  in  good  health,  and  her  menses  were  regular. 

The  uterus  was  above  the  average  size,  but  not  much  so.  The 
left  wall  was  more  than  twice  the  thickness  of  the  other,  so  that 
there  was  a  trace  of  the  fibroma  remaining,  but  it  -was  harmless. 
"While  the  object  for  which  the  ergot  was  originally  given  was  not 
attained  a  happier  result  followed. 

The  ergot  so  influenced  the  nutrition  of  the  growth  as  to  cause 
dropsy.  This  is  a  rare  effect  of  ergot,  and  yet  it  sometimes  is  pro- 
duced in  certain  cases. 

Submucous  Fibroma ;  Expulsion  by  the  Natural  Efforts  ;  Separation 
of  the  Pedicle  with  the  Ecraseur ;  Recovery. — The  patient  was  un- 
married and  thirty-five  years  old;  she  was  large,  strong,  and  had 
always  had  good  health.  She  began  to  menstruate  at  fourteen,  and 
continued  to  do  so  in  a  perfectly  normal  way  until  she  was  twenty- 
eight  years  old.  At  that  time  the  raenstnial  flow  became  more  free 
and  lasted  a  little  longer.  From  this  time  onward,  the  menstrual 
flow  gradually  but  not  regularly  increased,  until  she  established  a 
well-marked  menorrhagia.  This  undermined  her  health  consider- 
ably. She  lost  flesh,  and  became  quite  anaemic.  She  had  charge  of 
a  branch  of  a  large  business  establishment,  and  was  an  efficient  and 
trusted  employe,  but  her  duties  became  very  trying  to  her,  esj^e- 
cially  at  her  menstrual  periods,  at  which  times  she  was  obliged  to 
stay  at  home  occasionally.  Still  she  persisted  in  her  work  until  she 
was  taken  ill  and  confined  to  her  bed.  She  called  in  a  poorly-quali- 
fied physician  who  failed  to  relieve  her ;  subsequently  her  employer 
requested  me  to  take  her  in  charge.  I  found  the  uterus  enlarged 
from  the  pressure  of  a  fibroma,  which  was  evidently  intra-uterinc. 
She  also  had  all  the  signs  and  symptoms  of  a  pelvic  cellulitis  in  the 
left,  broad  ligament.  This  terminated  in  resolution,  and  in  about 
two  weeks  she  was  able  to  be  around  again.  Although  still  weak, 
she  retm*ned  to  her  duties,  but  lier  menorrhagia  continued.     Every 


FIBROMA   OF  THE   UTERUS.  381 

effort  was  made  by  tonics  and  good  food  to  improve  her  strength. 
She  was  requested  to  rest  at  her  menstrual  periods,  and  to  take  ergot 
and  cannabis  Indica  in  moderate  doses  at  such  times.  Slie  con- 
tinued to  bo  quite  anaemic,  but  dragged  along  with  her  work  as 
best  she  could.  I  saw  her  only  occasionally,  and  found  that  the 
tumor  did  not  grow  very  fast,  and  she  did  not  lose  much  in  general 
strengtli.  This  went  on  for  six  years,  when  she  began  to  have  se- 
vere pains  from  uterine  contractions ;  for  this  I  saw  her  and  sug- 
gested that  she  should  give  up  the  use  of  ergot.  I  did  not  see  her 
again  for  about  live  months,  when  I  was  called  in  haste  to  her,  and 
found  her  suffering  from  great  expulsive  pains.  She  told  me  that 
it  was  time  for  her  to  menstruate,  but  she  had  had  very  little  flow, 
but  instead  these  extreme  pains.  Examining  the  abdomen,  I  found 
that  the  size  of  the  uterus  was  greatly  increased,  and  that  in  the 
absence  of  uterine  contractions,  there  was  distinct  fluctuation  at  the 
ujDper  third  of  the  uterus.  I  presumed  that  the  fluctuating  mass 
was  a  cyst  which  had  rapidly  developed  since  the  time  that  I  had 
seen  her  before.  On  making  a  vaginal  examination,  I  found  the 
cervix  dilated  about  two  inches  and  a  solid  fibroma  protruding  at  the 
OS  externum.  Opium  was  given  to  ease  the  pain  which  was  ex- 
hausting her,  and  at  the  end  of  twelve  hours  I  found  that  although 
the  pains  had  modified  a  little,  they  had  continued.  The  dilatation 
of  the  cervix  had  progressed.  The  opium  was  continued  in  large 
doses.  It  was  then  night,  and  I  desired  her  to  sleep.  The  night 
was  passed  fairly  well,  she  had  j)ains,  but  slept  between  them.  JJ^ext 
day  the  opium  was  suspended  and  the  pains  returned  with  renewed 
vigor.  Toward  evening,  after  having  several  violent  pains,  they 
ceased,  but  were  followed  by  the  most  distressing  pressure  upon 
the  rectum  and  bladder.  There  was  no  cessation  to  this  suffering, 
and  I  was  called  in  haste  to  see  her.  I  found  the  tumor  the  size  of 
a  fetal  head,  pressing  upon  the  peringeum  and  firmly  impacted  in 
the  pelvis.  The  fluctuating  mass  was  still  felt  in  the  pelvis  but 
lower  down.  Her  sufferings  were  such  from  the  complete  obstruc- 
tion of  the  rectum  and  bladder  that  immediate  relief  was  de- 
manded. 

She  was  at  once  conveyed  to  a  private  room  in  the  hospital,  and 
the  removal  of  the  tumor  effected.     The  operation  was  as  follows : 

It  was  impossible  to  determine  the  location  or  character  of  the 
attachment  of  the  tumor,  nor  could  I  pass  the  chain  of  the  ecraseur 
over  it,  so  firmly  was  it  fixed  in  the  vagina.  To  avoid  incision  of 
the  pelvic  floor  and  delivery  of  the  tumor  en  masse — a  very  bad 
method  which  has  been  practiced — I  determined  to  diminish  the 


382  DISEASES   OF   WOMEN. 

size  of  the  mass  by  exsection  with  the  scissors  and  forceps.  It  was 
iii^ht,  so  I  hud  to  use  artificial  light  reflected  from  the  head-mirror. 
Through  Sims's  si)ecuhim  it  was  easy  to  cut  away  enough  to  enable 
me  to  determine  that  the  pedicle  was  not  large,  and  that  the  chain 
of  the  ecnisexir  could  be  passed,  AVhile  making  this  examination, 
and  also  while  adjusting  the  chain,  there  was  considerable  discharge 
of  dark  l>lood  from  above  the  tumor.  The  pedicle  was  easily  di- 
vided, and  the  remains  of  the  tumor  were  further  reduced,  so  that 
it  could  be  brought  through  the  vulva  without  laceration.  The  re- 
moval of  the  mass  was  followed  by  a  gush  of  dark  blood,  at  least 
a  pint  in  all,  and  there  were  several  clots  which  remained  in  the 
vagina.  These  were  rapidly  removed,  and  then  I  could  see  the 
distended  and  empty  uterus.  The  blood  had  accumulated  in  the 
uterus  above  the  tumor,  and  given  rise  to  the  fluctuation  and  rapid 
increase  in  the  size  of  the  uterus  which  I  had  observed. 

With  the  light  reflected  from  the  head-mirror  I  was  able  to  ex- 
amine the  entire  cavity  of  the  uterus  most  thoroughly.  By  holding 
the  lips  of  the  os  externum  apart  with  an  elevator  and  sponge-holder, 
the  view  of  the  interior  of  the  uterus  was  complete.  The  site  of 
the  attachment  of  the  tumor  could  be  clearly  seen,  and  the  gradual 
contraction  of  the  uterus  was  also  noted. 

There  was  nothing  of  interest  in  the  after-history  of  the  case. 
The  patient  made  a  good  recovery,  and  gradually  regained  her  health 
and  strength.  It  is  now  four  years  since  the  operation,  and  she  has 
continued  in  perfect  health. 

Uterine  Fibroma,  supposed  to  be  a  Uterine  Fibro-Cyst ;  Death  from 
Septicaemia  during  the  Process  of  Expulsion. — An  unmarried  lady  of 
somewhat  delicate  organization  came  under  my  observation  when 
she  was  thirty  years  of  age ;  she  said  that  five  years  previously  she 
began  to  suffer  from  menorrhagia,  and  soon  afterward  began  to  ob- 
serve a  gradual  increase  in  the  size  of  the  abdomen.  When  fii^st 
seen,  the  tumor  was  about  the  size  of  the  uterus  at  the  seventh 
month  of  gestation;  all  the  physical  signs  of  a  submucous  fibroma 
were  obtained.  Her  general  health  was  somewhat  impaired,  she 
was  anaemic,  owing  to  the  menorrhagia,  which  was  not  excessive; 
otherwise  she  was  in  fairly  good  health,  and,  as  her  circumstances 
in  life  were  good,  she  was  able  to  be  around  and  enjoy  life.  She 
was  placed  upon  a  general  tonic  treatment,  with  the  use  of  ergot  and 
cannabis  Indica,  which  were  given  at  the  menstrual  period.  She 
continued  for  three  years  to  do  fairly  well,  occasionally  having  an 
attack  of  menorrhagia,  which  pulled  her  down  a  little,  but  she  readily 
recovered  from  this,  and  went  about  in  her  usual  way. 


FIBROMA  OF  THE  UTERUS.  383 

Slie  was  seen  only  occasionally,  and  the  general  plan  of  treatment 
was  not  changed. 

About  the  fonrth  year  after  she  came  under  my  observation,  she 
had  an  attack  of  monorrhagia  which  was  rather  more  severe  than 
usual,  and  she  took  larger  doses  of  ergot,  and  continued  the  remedy 
longer  than  was  her  habit.  This  controlled  the  menorrhagia  but 
produced  severe  uterine  pain,  for  which  I  was  called  to  prescribe. 
I  then  carefully  examined  the  tumor  and  found  that  it  had  increased 
in  size  considerably  from  the  time  1  had  seen  her  before — about  four 
or  five  months.  I  found  that  the  upper  portion  of  the  tumor  was 
quite  elastic,  and  that  there  was  distinct  fluctuation  extending 
through  an  area  of  about  five  inches.  I  then  suspected  a  fibro- 
cyst. 

Soon  after  this  she  was  seen  by  my  distinguished  friend,  Dr.  T.  G. 
Thomas,  who,  without  knowing  of  the  patient's  histoiy  or  my  own 
opinion,  made  the  diagnosis  of  fibro-cyst.  During  the  remainder  of 
that  winter  and  the  next  spring  she  had  more  menorrhagia,  and  was 
kept  more  continually  under  the  influence  of  ergot ;  when  summer 
came  she  had  regained  some  of  her  former  strength,  and  went  to  the 
country,  where  she  remained  for  several  months.  She  returned  in 
the  autumn  slightly  improved,  but  about  a  month  afterward  began 
to  suffer  from  severe  pains,  due  to  uterine  contractions.  These  pains 
increased  in  severity  and  frequency,  until  she  was  unable  to  leave 
her  room.  She  then  sent  for  me,  when  to  my  surprise  I  found  the 
cervix  uteri  fully  dilated  and  the  tumor  partially  expelled  from 
the  uterus,  occupying  and  completely  filHng  the  vagina.  The  ergot 
was  suspended,  and  she  was  relieved  from  her  severe  pain  by  the 
use  of  opium,  but  the  pressure  upon  the  pelvic  organs  became  so 
great  that  it  was  necessary  to  try  and  relieve  her.  The  lower  por- 
tion or  capsule  of  the  tumor  began  to  slough,  and  I  then  determined 
to  remove  all  of  the  tumor,  or  as  much  of  it  as  possible.  In  the 
mean  time  the  uterus  as  examined  through  the  abdominal  wall 
had  not  diminished  very  much  in  size,  and  the  fluctuation  was  more 
marked  and  more  extensive.  She  was  at  this  time  very  anaemic,  and 
so  weak  that  I  dared  not  anaesthetize  her.  So  I  proceeded  without 
doing  so,  with  the  patient  in  Sims's  position,  and  with  the  aid  of 
Sims's  speculum  I  rapidly  removed  all  that  portion  of  the  tumor 
which  occupied  the  vagina,  using  the  tenaculum  forceps  and  haemo- 
static scissors.  There  was  very  little  haemorrhage,  and  the  patient 
derived  very  great  relief  from  the  removal  of  this  portion.  She  was 
permitted  to  rest  for  a  few  days  and  ergot  was  again  given,  which 
produced  expulsion  of  another  mass  about  as  large  as  the  one  that 


384  DISEASES  OF  WOMEN. 

had  b'jen  expelled,  this  was  removed  in  the  same  way  as  the  other; 
while  removing  a  portion  whieh  extended  up  into  the  cervix  uteri, 
about  live  or  six  ounces  of  Huid  escaped  from  the  cavity  of  the 
uterus.  Immediately  after  tliis  it  was  found  that  the  fluctuation  was 
greatly  lessened,  and  the  size  of  the  tumor,  as  observed  through  the 
abdominal  walls,  had  markedly  diminished.  She  had  after  this  con- 
siderable fever  and  disturbance  of  the  stomach,  and  this,  along  with 
her  marked  anaemia,  prostrated  her  so  that  nothing  could  be  done 
for  nearly  a  week  but  to  sustain  her.  At  the  end  of  that  time  her 
temperature  diminished  somewhat,  she  was  able  to  take  nourishment 
and  stinmlants,  and  as  considerable  more  of  the  tumor  had  been  ex- 
pelled, a  third  attempt  was  made  to  remove  it.  I  was  able  to  re- 
move all  that  portion  outside  of  the  cervix ;  I  then  endeavored  to 
remove  a  portion  that  was  still  within  the  grasp  of  the  cervix ;  as 
soon  as  I  did  this,  about  four  ounces  of  putrid  matter  were  discharged 
from  the  uterus.  Although  there  was  not  much  haemorrhage,  and 
the  patient  did  not  complain  of  pain,  she  was  so  much  exhausted  and 
her  pulse  was  so  feeble  that  I  was  obliged  to  desist,  feeling  confident 
that  if  I  undertook  to  remove  the  remainder  of  the  tumor,  the 
patient  would  succumb.  The  cavity  of  the  uterus  was  carefully 
washed  out  with  carbolized  water,  and  the  patient  put  to  bed  and 
stimulated  and  nourished  as  well  as  possible.  Two  days  afterward, 
when  she  had  rallied  considerably,  I  found  that  the  lower  por- 
tion of  the  cervix  had  contracted  around  the  tumor,  and  that  it  was 
breaking  down  and  decomposing.  I  thoroughly  and  repeatedly 
washed  out  the  inner  cavity  of  the  uterus,  and  hoped  by  so  doing  to 
control  the  septicaemia  from  which  she  was  suffering  in  a  most 
marked  degree.  I  also  felt  confident  that  if  I  could  bring  her 
strength  up  again  that  I  might  be  able  to  remove  the  whole  of  the 
tumor.  But  this  proved  to  be  impossible,  although  the  uterus  con- 
tracted again,  in  fact,  sufiiciently  expelled  the  tumor  to  partially 
dilate  the  cervix.  She  at  no  time  was  in  any  condition  to  bear  so 
formidable  an  operation  as  completing  the  enucleation  of  the  tumor. 
The  septicaemia  still  proceeded,  and  she  died  about  five  years  from 
the  time  that  she  first  came  under  my  observation. 

On  post-mortem  examination  it  was  found  that  a  portion  of  the 
fibroma  as  large  as  a  fetal  head  remained,  and  was  attached  at  the 
posterior  and  right  lateral  wall  of  the  uterus,  and  that  it  closed  the 
cavity  very  tliorouglily  by  pressure,  and  that  there  was  still  a  little 
fluid  in  the  fundus  uteri.  It  was  clearly  evident  from  this,  that  this 
obstruction  of  the  canal  below  and  the  distention  of  the  ca\nty  of 
the  uterus  above,  whieh  gave  rise  to  the  fluctuation  obtained  at  her 


FIBROMA   OF  THE   UTERCS.  385 

examination,  explained  the  resemblance  of  the  physical  signs  to  tliose 
obtained  in  the  uterine  libro-cysts. 

It  is  a  number  of  years  since  this  case  came  under  my  observa- 
tion, and  I  am  satisfied  that  liad  I  known  then  as  much  as  I  know 
now  about  the  management  of  such  cases  I  should  probably  have 
been  able  to  save  her.  As  it  is,  I  still  think  that  had  she  sent  for  me 
when  she  returned  from  the  country,  and  before  her  strength  became 
so  nnicli  exhausted  from  the  efforts  at  expulsion,  I  might  have  been 
able  to  remove  tlie  whole  of  the  tumor ;  but  it  was  otherwise. 

A  Case  of  Submucous  Fibroma  in  which  Pregnancy  progressed  to 
Full  Time,  and  the  Tumor  was  completely  expelled  about  a  Week 
after  Confinement. — This  case  was  seen  in  consultation  with  Dr. 
Bodkin,  who,  when  called  to  attend  her  in  confinement,  found  a 
solid  tumor  which  so  completely  filled  the  pelvis  that  he  could  not 
reach  the  os  uteri.  The  labor-pains  continued,  tbe  membranes 
ruptured,  and  the  cord  became  prolapsed.  The  tumor  was  recognized 
as  a  fibroma  which  extended  down  into  the  cervix  and  at  the  same 
time  upward  toward  the  fundus.  It  was  a  long,  narrow  tumor  which 
may  have  assumed  that  shape  by  stretching  during  the  growth  of 
the  pregnant  uterus. 

We  agreed  to  try  to  deliver  by  version.  Accordingly,  when  the 
patient  was  anaesthetized  the  doctor  succeeded  in  pushing  up  the 
tumor  out  of  the  pelvis,  and  passing  his  hand  past  the  tumor  and 
through  the  os,  which  was  quite  dilatable,  be  turned  and  delivered. 

I  then  took  charge  of  the  placenta,  which  was  retained  for  some 
time.  To  facilitate  its  delivery  and  at  the  same  time  to  investigate 
the  tumor,  I  passed  my  hand  into  the  uterus  and  was  able  to  make 
out  by  bimanual  touch  the  size  and  location  of  the  tumor.  It  was 
oblong,  as  already  stated,  and  situated  in  the  anterior  wall  a  little  to 
the  left  side,  and  extended  from  the  cervix  nearly  to  the  fundus, 
and  evidently  was  immediately  beneath  the  mucous  membrane. 

The  patient  did  very  well  considering  all  things  ;  she  had  con- 
siderable hsemorrhage  at  the  time,  and  the  discharge  afterward  was 
free  and  at  times  offensive,  and  she  had  long-continued  after-pains. 

About  seven  or  eight  days  after  her  confinement  she  had  an  at- 
tack of  tenesmus,  and  in  the  hope  of  obtaining  relief  she  got  up  to  the 
commode,  and  by  vigorous  expulsive  efforts  expelled  the  tumor.  It 
was  much  shrunken,  no  doubt,  but  even  then  the  doctor  estimated 
that  it  was  about  seven  inches  in  length  and  three  inches  in  diam- 
eter.    She  subsequently  did  well. 

In  this  connection  it  may  be  stated  that  uterine  fibromata  cause 
sterihty,  as  a  rule,  owing  perhaps  to  the  endometritis  which  is  usu- 
26     , 


386  DISEASES   OF   WOMEN. 

ally  present,  and  when  preu^naney  takes  place  miscarriage  generally 
occurs.  Still,  1  have  seen  at  least  four  cases  that  went  to  full  time. 
In  all  except  the  one  recorded  above  the  tumors  were  subperitoneal 
and  not  laruv. 

Extreme  Dilatation  of  the  Cervix  TJteri  and  Expulsion  of  a  Sub- 
mucous Fibroma  while  only  Slightly  Pedunculated;  The  Case  diag- 
nosticated as  Inversion  of  the  Uterus;  Operation  and  Recovery. — 
This  patient  came  to  my  hospital  clinic  and  gave  a  history  of  mcuijr- 
rhagia  for  years,  and  for  several  months  past  a  metrorrhagia  and 
uterine  pain.  She  was  quite  anaemic,  but  had  always  been  well  and 
strong  until  the  excessive  menstruation  came.  She  also  stated  that 
she  visited  the  outdoor  department  of  the  Woman's  Hospital  of  New 
York,  and  the  gentleman  who  saw  her  said  that  her  womb  was 
turned  inside  out,  that  she  should  enter  the  hospital  for  operation, 
and  that  her  case  was  a  dangerous  one, 

I  presumed  that  the  diagnosis  made  was  inversion  of  the  uterus, 
and  on  asking  the  doctor  about  the  case  he  told  me  that  he  believed 
it  to  be  so.  On  my  first  examination  I  found  a  tumor  in  the  va- 
gina which,  in  size  and  shape,  was  exactly  like  an  inverted  uterus. 
The  mass  was  covered  with  uterine  mucous  membrane.  Absence 
of  the  fundus  and  body  of  the  uterus  in  the  upper  part  of  the  pel- 
vis was  observed  by  the  bimanual  touch.  That  portion  of  the  mass 
which  was  uppermost  was  larger  than  that  which  is  usually  found 
in  inversion  of  the  uterus,  but  in  the  center  of  it  there  was  a  slight 
depression  which  is  generally  found  in  inversion.  Passing  the 
sound  around  the  tumor  gave  evidence  that  the  vagina  was  at- 
tached to  the  upper  part  of  the  tumor,  but  by  pressing  the  tumor 
to  one  side  and  separating  the  vagina  from  it,  I  could  see  that  there 
was  uterine  mucous  membrane  above  the  vagina,  which  extended 
upward,  inward,  and  over  the  tumor.  By  seizing  the  tumor  and 
t^^^sting  it  round  upon  its  axis,  I  also  observed  that  the  upper  ])art 
of  the  vagina  did  not  move  with  it  as  would  have  been  the  case  if 
there  had  been  inversion  of  the  uterus.  From  these  signs  I  con- 
cluded that  the  tumor  was  a  fibroma,  with  a  small  but  very  short 
pedicle  attached  to  the  fundus  uteri,  and  that  the  cer\dx  and  lower 
portion  of  the  uterus  were  so  completely  dilated  that  the  vaginal 
and  uterine  walls  were  continuous. 

I  presume,  that  in  time,  the  tumor  would  have  dragged  the  fun- 
dus uteri  downward  and  produced  inversion.  This  has  occurred. 
In  fact,  it  is  not  an  unusual  thing  to  find  a  partial  inversion  of  the 
uterus  caused  by  fil)romata  during  their  expulsion. 

The  pedicle  was  divided  with  the  ecraseur  and  the  tumor  re- 


FIBROMA   OF  THE   UTERUS.  387 

moved.  The  cavity  of  the  uterus  then  appeared  like  a  cup-shaped 
dome  at  the  termination  of  the  vagina.  A  sponge,  in  a  holder,  was 
gently  pressed  against  the  fundus  uteri,  and  held  there  until  the 
uterus  conti'acted,  which  it  did  quite  slowly.  This  was  done  to  pre- 
vent a  possible  inversion  from  taking  place.  The  patient  recov- 
ered very  promptly. 

Soft  Fibroma  ;  Atrophy  of  the  Muscular  Wall  of  the  Uterus  at  the 
Point  of  Attachment  of  the  Tumor ;  Enucleation  after  Dilatation  of  the 
Cervix  Uteri  and  Partial  Expulsion;  Recovery. — The  jjatient  was 
forty-nine  years  old,  m.irried,  and  had  had  two  children,  the  last  one 
sixteen  years  before  the  time  when  she  came  under  my  care.  She 
was  a  strong,  healthy  lady,  and  had  been  weL  until  she  was  about 
forty-hve  years  of  age.  At  that  time  she  began  to  menstruate  more 
freely  than  at  any  previous  time  in  her  life,  but  being  told  that  it  was 
due  to  "change  of  life"  she  did  nothing  for  it,  until  she  became  so 
weak  that  she  sought  advice  of  a  practitioner  who  treated  her  locally 
for  ulcei'ation  of  the  cervix  which  he  said  she  had.  She  grew  worse, 
the  bleeding  was  more  free  and  lasted  longer  at  each  period,  and 
she  had  a  profuse  watery  discharge  at  other  times.  Then  uterine 
pains  came  on,  which  she  said  were  like  the  first  pains  of  labor. 
This  was  the  history  which  I  obtained  when  called  to  see  her  the 
first  time. 

On  examination  I  found  the  cervix  well  dilated,  and  part  of  a 
soft  fibroma  occupying  and  filling  the  upper  part  of  the  vagina. 
The  pressure  gave  her  much  discomfort,  and  I  found  that  the  por- 
tion in  the  uterus  was  quite  as  large  as  that  which  occupied  the 
vagina.  Without  giving  the  patient  an  anaesthetic,  I  removed  all 
that  was  outside  of  the  uterus  with  the  ecraseur.  There  was  no 
pain  and  very  little  bleeding  caused  by  the  operation.  The  patient 
being  fatigued  by  remaining  in  Sims's  position  I  did  nothing  more 
for  two  days,  and  at  the  end  of  that  time  the  larger  part  of  the 
mass  was  expelled  from  the  uterus.  It  was  oblong  but  not  pedun- 
culated. All  that  was  protruding  from  the  os  externum  was  re- 
moved with  the  ecraseur^  and  the  stump  was  seized  with  a  double 
tenaculum  forceps  and  enucleated.  Traction  being  made  with  the 
forceps  the  mass  was  separated  from  the  capsule  with  a  blunt  cu- 
rette. There  was  very  httle  pain  caused  until  the  mass  was  sepa- 
rated all  round  and  the  deepest  attachment  was  reached.  Then  the 
patient  began  to  complain.  This  was  fortunate,  because  it  made  me 
very  careful.  I  simply  made  steady  traction  and  counter-pressure 
with  the  curette.  When  the  mass  came  away  I  could  see  the  peri- 
tonaeum very  plainly  at  the  bottom  of  the  cavity.     My  assistant 


388  DISEASES  OF   WOMEN. 

also  observed  it,  uiul  recognizing  wliiit  it  was,  he  naturally  was  quite 
anxious.  A  space,  about  t!ie  size  of  a  twenty-five  cent  i)iece  was  ex- 
posed. It  had  not  been  wounded  at  all,  but  appeared  as  if  it  had 
separated  from  tiie  tumor  very  easily.  To  make  sure  that  there  was 
no  mistake  I  examined  by  the  touch  and  found  the  parts  exactly  as 
they  aj)peared  to  be  on  inspection. 

Submucous  Fibroma  of  Large  Size  extending  through  the  Uterine 
Wall  to  the  Peritoneum ;  treated  firct  by  Partial  Exsection  with  the 
Galvano-Cautery  and  Several  Years  after  by  Enucleation;  Recovery. — 
This  was  a  liospital  case  which  1  saw  with  Dr.  Cushing.  The  tumor 
was  large,  and  extended  down  into  the  cervix  on  one  side  and  could 
be  easily  reached.  The  patient  was  suffering  greatly  from  bleed- 
ing. Partial  excision  was  made  by  passing  two  large  curved  needles 
thi'ough  a  section  of  the  tumor,  and  then  passing  the  wire  be- 
low the  needles,  and  cutting  it  off  by  heating  the  \vire.  Section 
after  section  was  removed  in  this  way,  until  all  that  portion  which 
could  be  reached  conveniently  was  removed,  about  two  thirds  of  the 
whole,  perhaps.  The  operation  was  long,  and  I  did  not  think  it 
prudent  to  continue  the  efforts  to  remove  the  whole  mass.  Recov- 
ery from  the  operation  was  without  interruption,  and  the  patient 
was  much  improved.  The  menorrliagia  subsided,  she  gained  her 
former  strength,  and  was  able  to  make  her  living  as  a  laundress. 

In  a  few  years  the  tumor  had  grown  again,  and  all  the  old 
symptoms  returned  and  were  worse  than  ever.  Dr.  Cushing  had  to 
see  her  for  several  attacks  of  menorrhagia,  which  nearly  proved 
fatal.  She  then  came  into  the  hospital.  The  tumor  was  nearly  as 
large  as  it  w^as  before,  and  she  was  extremely  feeble  and  anaemic. 
There  was  a  cardiac  mitral  murmur.  The  officers  of  the  hospital 
strongly  advised  that  I  should  not  operate,  and  I  would  have  gladly 
followed  their  advice,  but  the  patient  begged  that  I  should  try 
again  to  help  her,  and  I  agreed  to  do  so.  The  tumor  was  low  down 
in  the  pelvis  and  projected  beyond  the  opposite  side  of  the  cervix. 

Ether  Avas  given,  and  the  pulse  improved  a  little  under  its  influ- 
ence. The  capsule  was  di\nded  with  the  therm o-cauterv,  and  sepa- 
rated from  the  tumor  over  its  exposed  portion.  A  strong  forceps 
was  fixed  in  the  mass,  and  while  strong  traction  was  being  made 
the  enucleation  was  performed  with  the  spoon-saw  of  Thomas. 
When  I  had  nearly  completed  the  separation,  I  noticed  that  there 
was  very  little  resistance  on  the  part  of  the  uterine  wall  at  the 
upper  part ;  I  then  made  a  bimanual  examination  and  found  that 
I  had  passed  through  the  muscular  coat  of  the  uterus  entirely. 
I  was  fearful  that  if  I  made  any  further  effort  to  complete  the 


FIBROMA   OF   THE    UTERUS.  389 

enucleation  I  might  wound  the  peritoniEum.  The  detached  por- 
tion was  separated  from  the  rest,  and  the  operation  stopped.  The 
portion  left  was  about  the  size  of  a  hen's  egg.  There  was  not 
much  bleeding,  but  I  can  only  say  that  the  patient  was  living  when 
she  was  put  to  bed.  The  uterus  contracted  fairly  well.  There  was 
no  further  lijemorrhagc,  but  a  free  discharge  of  serum  continued  for 
a  number  of  days.  I  felt  sorry  that  I  had  not  been  able  to  remove 
the  whole  of  the  tumor,  but  was  glad  that  her  life  had  l)een  spared. 
She  improved  slowly  in  strength,  and  was  able  to  leave  the  hospital 
in  three  weeks.  The  heart-murmur,  which  was  presumed  to  be 
largely  due  to  her  extreme  anaemia,  proved  to  be  due  to  mitral  in- 
sufficiency, and  although  she  had  no  more  trouble  from  menorrhagia, 
she  did  not  fully  regain  her  strength.  She  took  wp  her  old  occu- 
pation, but  it  was  more  than  her  strength  could  endure.  A  little 
over  two  years  after  the  operation  she  died  suddenly  of  heart-fail- 
ure. The  post-mortem  revealed  the  heart  lesions  which  proved 
fatal.  The  part  of  the  tumor  which  was  left  had  not  grown,  in 
fact,  it  probably  had  diminished.  The  scar  at  the  point  of  the 
deepest  enucleation  showed  that  there  was  no  middle  coat  of  the 
uterus  at  the  side  of  attachment  of  the  tumor.  These  facts  proved 
conclusively  that  in  operating  I  had  gone  through  to  the  perito- 
naeum, as  I  thought  I  did  at  the  time. 

The  following  cases,  treated  by  hysterectomy,  are  from  the  work 
of  Dr.  Thomas  Keith : 

Large  Solid  Fibroid,  Weight,  Forty-two  Pounds ;  Supra-Vaginal 
Hysterectomy;  Recovery.  (Keith).— Mary  C,  aged  twenty-eight, 
was  sent  into  the  Royal  Infirmary  by  Dr.  Robertson,  of  Ardros- 
san.  She  had  sought  relief  in  many  quarters  in  vain.  The  tumor 
was  very  large,  and  was  first  noticed  five  or  six  years  before.  She 
M'as  wasted  about  the  chest  and  arms,  like  a  case  of  old  ovarian 
disease. 

The  abdomen  measured  forty-nine  inches  at  the  umbilicus ;  the 
tumor  was  firm  and  solid  throughout.  The  ensiform  cartilage  was 
turned  upward,  and  the  growth  extended  under  the  sternum  and 
ribs ;  close  to  the  sternum  there  was  a  large  projection  the  size  of  a 
cliild's  head.  No  trace  of  the  ovaries  could  be  detected.  The  greater 
part  of  the  pelvis  was  occupied  by  the  tumor.  There  was  no  dis- 
tinct cervix,  only  a  small  triangular  projection  drawn  to  the  left 
side,  almost  beyond  reach  of  the  finger.  For  several  years  no  great 
inconvenience  had  resulted  ;  menstruation  was  never  in  excess,  and 
for  the  last  fifteen  months  it  had  entirely  ceased ;  since  then,  the 
increase  in  the  tumor  had  been  rapid,  and  she  could  do  little  or  noth- 


390  DISEASES   OF   WOMEN. 

ing  owing  to  its  weiglit.  Slie  sat  all  day  knitting;  at  twenty -eight, 
her  life-prospeets  were  anything  bnt  bright. 

For  ob^^ous  reasons,  this  patient  was  not  taken  down  to  the 
large  theatre,  l)nt  was  operated  on  in  the  ward,  on  the  18th  of  April, 
1881.  Sulphuric  ether  was  given,  and  the  operation  was  performed 
under  carbolic-acid  spray.  The  sponges,  thirty  in  number,  had 
been  lying  for  a  long  time  in  a  five-i)er-cent  solution  of  carbolic 
acid ;  they  were  washed  in  hot  water,  and  then  put  into  a  two-per- 
cent solution,  and  wTung  almost  dry.  These  were  used  over  and 
over  again,  and  were  not  washed  in  any  fresh  solution  during  the 
operation.  Dr.  Wilson  was  present  from  Glasgow,  and  there  were 
about  twenty  visitors  and  students.  The  lirst  incision  measured 
twelve  inches  ;  it  terminated  four  inches  abo\'e  the  pubes,  so  as  to 
avoid  the  bladder,  which  was  to  be  elevated  on  the  tumor.  On  the 
right  side,  the  broad  ligament  rose  as  high  as  the  crest  of  the  ilium. 
The  left  broad  ligament  was  largely  spread  over  the  half  of  the 
tumor  as  high  up  as  the  ribs.  The  opening  was  then  enlarged  to 
twenty-two  inches,  and,  by  dint  of  hard  pushing  and  patience,  the 
huge  mass  was  slowly  moved  forward  as  far  as  its  cpnnection  on  the 
left  side  would  permit. 

The  right  ovary  was  easily  seen.  On  searching  for  the  left,  it 
was  found  to  be  transformed  into  a  long,  tense,  umbilical-like  cord, 
seven  or  eight  inches  in  length.  Here  and  there  along  this  tense 
band  were  several  small  cysts.  It  was  so  imbedded  in  the  tumor 
that  it  never  could  have  been  removed.  The  right,  broad  ligament 
was  transfixed  by  soft-iron  wires,  secured  and  divided ;  all  bleeding 
from  the  tumor  was  prevented  by  a  series  of  strong-locking  forceps. 
The  fibroid  was  now  more  easily  dealt  with.  It  was  drawn  for- 
ward, so  as  to  put  on  the  stretch  its  enormous  connection  on  the 
left  side.  About  a  dozen  powerful-locking  forceps,  ten  inches  in 
length,  were  now  applied  to  the  broad  ligament  l)efore  and  l)ehind. 
The  whole  was  then  cut  downward,  and  the  mass  enucleated  as  low 
as  possible.  A  strong,  soft-iron  ligature  embraced  the  base,  which 
was  of  great  thickness. 

The  tumor  was  then  cut  away,  the  stump  showing  a  section  of 
the  cervix  in  the  center.  The  forceps  were  removed  one  by  one, 
and  all  bleeding  vessels  separately  tied.  Some  of  these  were  large, 
and  one  threw  blood  over  the  assistant's  head.  There  was  much 
trouble  in  finding  some  bleeding  points  among  the  loose  cellular 
tissue  of  the  huge  gap  now  left. 

The  hnemorrhage  was  mostly  venous.  All  present  could  see  that 
the  condition  was  full  of  danger,  and  that  secondary  htemorrhage 


FIBROMA   OF   THE   UTERUS.  391 

into  this  loose  tissue  was  not  one  of  the  smallest  risks  of  the  opera- 
tion. When  all  oozing  seemed  to  have  ceased,  the  stump  (the  thick- 
ness of  the  leg)  and  the  end  of  the  right,  broad  ligament  were  se- 
cured, with  much  tension,  outside ;  a  glass  drainage-tube  was  fixed 
in  above  the  stump,  and  the  wound  closed  bj  forty  silk  sutures. 
The  operation  lasted  one  hour  and  three  quarters.  After  much 
blood  and  serum  had  escaped  from  the  tumor,  its  weight  was  forty- 
two  pounds. 

Ten  hours  after  the  operation,  five  ounces  and  a  half  of  sirupy 
blood  were  removed  from  the  pelvis  through  the  tube.  The  pulse 
was  94 ;  the  temperature  102'2° ;  rising  two  hours  afterward  to 
103*4°.  During  the  night,  back-pain  was  relieved  by  injections  of 
morphia. 

The  first  day  was  passed  fairly  well.  In  the  evening  the  pulse 
was  120,  and  the  temperature  102*2° ;  flatulence  was  troublesome. 
She  felt  weak,  and  had  whisky  and  water  to  drink.  There  were 
only  four  ounces  of  bloody  serum  from  the  tube. 

On  the  third  morning,  the  pulse  was  120,  and  the  temperature 
104°. 

On  the  fourth  day,  the  pulse  was  114  to  125  ;  the  temperature 
ranged  from  101°  to  103*5°. 

On  the  fifth  day,  after  a  restless  night,  the  temperature  had  risen 
to  100° ;  it  fell  to  104°,  and  again  in  the  afternoon  it  rose  to  105*5.° 
There  was  oedema  of  the  labia,  and  much  cellular  infiltration  in  the 
pelvis.  She  looked  very  ill  during  these  days,  not  caring  for  food, 
though  taking  stimulants  freely  ;  on  the  sixth  day  the  pulse  dropped 
to  92,  and  the  temperature  also  fell  to  101*0°.  The  tube  was  re- 
moved, there  being  only  a  tablespoouful  of  reddish  serum  in  the 
pelvis.  On  the  ninth  day  the  wound  was  found  healed  throughout. 
The  stump  was  dry  and  sweet.  The  pulse  and  temperature  almost 
normal. 

In  the  third  week  there  was  again  a  rise  of  pulse,  and  of  tem- 
perature from  101°  to  103.°  This  continued  for  ten  days,  and 
caused  some  anxiety. 

On  the  eighteenth  day,  the  wires  were  loose  and  were  removed. 
The  loop  was  two  inches  and  three  quarters  in  diameter.  Seven 
weeks  after  the  operation  she  left  the  hospital.  She  is  now  a  strong 
woman,  in  perfect  health,  and  can  do  anything. 

Soft  Bleeding  Fibroid;  Intra-Peritoneal  Treatment  of  Pedicle; 
Recovery.  (Keith). — In  1870,  Dr.  Kidd,  of  Alyth,  sent  me  an  un- 
married woman — a  domestic  servant — with  a  fibrous  tumor,  low  in  the 
pelvis  and  extending  to  the  umbilicus.     She  was  no  longer  able  foi* 


392  DISEASES  OF  WOMEN. 

her  situation,  partly  from  j^iiii  ;in<l  partly  from  excess  at  the  menstrual, 
periods.  She  was  twenty-nine  years  of  age,  and  of  fairly  healthy* 
appearance.  I  advised  her  to  delay  interference,  unless  such  be- 
came absolutely  necessary.  After  three  years  she  came  again,  very 
anxious  for  relief.  She  was  much  changed ;  the  tumor  now  filled 
the  abdomen  ;  she  was  extremely  ansemic,  and  (aiite  unlit  to  make 
her  living  in  any  way.  The  tumor  varied  much  in  size :  very  large 
and  tense  before  menstruation,  much  smaller  and  softer  after  this 
was  over.     The  loss  of  blood  was  sometimes  very  great. 

Operation  was  on  July  10,  1879.  Carbolic  spray  was  used. 
An  incision  not  exceeding  ten  inches  was  made ;  by  taking  time, 
the  tumor  molded  and  could  be  pushed  through  the  0})ening. 
Both  broad  ligaments  extended  up  to  the  fundus  of  the  tumor  on  a 
level  ^vith  the  ribs.  The  portion  containing  the  ovarian  vessels  was 
first  transfixed  aud  ligatured,  locking-forceps  beiug  put  on  close  to 
the  tumor,  before  the  ligament  was  divided.  The  same  process  was 
repeated  on  the  other  side.  The  tumor  was  then  separated  down- 
ward all  around  from  its  cellular  attachments,  and  a  soft-iron  wire, 
secured  quite  low  down — in  this  case,  almost  round  the  top  of  the 
vagina — by  Koeberle's  instrument.  There  was  thus  left  a  large 
cavity,  from  which  the  pelvic  portion  of  the  tumor  had  been  shelled 
out.  Koeberle's  instrument — five  and  a  half  inches  in  length — was 
left  dipping  into  the  pelvis,  as  it  could  not  be  secured  outside. 
There  was  little  bleeding  from  the  separated  surfaces,  and  the  wound 
was  kept  as  open  as  possible  around  the  instrument,  to  allow  of  the 
escape  of  serum. 

The  operation  lasted  one  hour  and  a  quarter.  There  was  a  good 
deal  of  pain,  and  several  opiates  were  required  during  the  afternoon, 
There  was  very  free  perspiration  for  some  days.  The  highest  pulse 
reached  was  124,  about  thirty  hours  after  the  operation  ;  the  highest 
temperature  was  100*5°.  Recovery  was  uninterrupted.  The  serre- 
noeud  came  away  with  the  slough  in  ten  days ;  she  returned  home 
thirty-two  days  after  the  operation,  the  wound  being  quite  cicatrized 
for  some  days. 

The  tumor  was  a  soft,  oedematous  fibroid,  and  weighed  nineteen 
pounds.    This  patient  has  enjoyed  perfect  health  since  the  operation. 

Fibrous  Tumor  of  Uterus,  containing  an  Inflamed,  Suppurating 
Cavity;  Operation;  Recovery.  (Keith). — An  unmarried  woman, 
aged  forty-four,  was  admitted  into  the  Koyal  Infirmary  in  February, 
1874,  under  Dr.  Matthews  Duncan.  She  was  a  pale,  thin,  un- 
healthy looking  woman.  She  had  granular,  everted  eyelids,  and 
was  half-blind  from  inflammation  of  the  cornea.     Up  till  the  pre- 


FIBROMA   OF  THE   UTERUS.  393 

vious  June  lier  health  was  fairly  good.  She  was  then  obliged  to 
give  up  her  situation  as  cook  in  London,  where  she  had  lived  for 
more  than  twenty  years. 

Menstruation  was  regular  and  normal.  Five  weeks  before  ad- 
mission a  tumor  was  detected.  It  was  hard,  elastic,  quite  fixed,  and 
reached  to  the  umbilicus.  The  cervix  was  drawn  to  the  left  side  of 
the  pelvis ;  it  was  almost  beyond  reach  of  the  finger,  and  felt  as  if 
lost  in  the  tumor.  This  was  supposed  to  be  ovarian.  I  never  had 
any  doubt  that  the  case  was  one  of  uterine  fibroid,  and  declined  to 
operate  on  it. 

After  two  months'  residence  in  the  hospital  she  was  dismissed, 
and  went  to  her  friends  in  the  north. 

In  the  course  of  the  summer  she  began  to  write  letters  to  say 
that  she  suffered  severely,  and  that  the  tumor  had  increased.  She 
was  imjjortunate,  and  wished  something  tried.  At  last,  wearied  by 
her  importunity,  she  was  allowed  to  come  back.  The  tumor  had 
certainly  got  much  larger ;  its  appearance  was  changed.  It  was 
very  tender  now,  and  had  become  prominent  on  the  right  side,  push- 
ing the  loin  outward.  There  was  some  free  fluid.  The  feeling  of 
elasticity  was  less  marked,  while  that  of  a  deep,  obscure  fluctuation 
was  pretty  distinct. 

The  relations  in  the  pelvis  were  the  same,  the  tumor  filling  the 
whole  upper  pelvis.  It  was  everywhere  fixed  and  immovable.  On 
September  5th,  a  needle  was  put  in  at  the  umbilicus,  and  sixty 
ounces  of  a  dark-bro^vn  fluid  were  removed.  This  was  pronounced 
to  be  ovarian.  There  was  little  apparent  diminution  of  the  tumor. 
Much  irritation  followed  the  puncture,  and  in  ten  days  the  tension 
was  greater  than  ever.  The  aspirator  was  again  used ;  the  same 
quantity  of  fluid,  which  was  again  said  to  be  ovarian  was  removed. 
This  time  much  relief  followed.  She  was  again  sent  away,  for  I 
had  not  changed  my  mind,  and  still  thought  the  tumor  was  uterine. 
She  was  encouraged  to  hope  that,  as  menstruation  seemed  about  to 
cease,  the  tumor  would  quiet  down. 

In  a  few  weeks  she  was  back  again,  urgent  for  operation  at  any 
risk ;  her  life  was  miserable  from  pain,  her  health  had  given  way, 
and  she  had  to  work  that  she  might  live.  The  case  was  now  quite 
a  clear  one  for  interference,  and  I  willingly  agreed  to  try  and  remove 
the  tumor,  the  patient  clearly  understanding  that  this  might  not  be 
accomplished. 

On  December  12th  an  incision,  twelve  or  fifteen  inches  was  made 
at  once.  The  tumor  was  of  a  dusky-brown  color,  covered  by  enor- 
mous veins.     It  was  firmly  attached  to  the  riglit  iliac  fossa,  right 


394  DISEASES   OF   WOMEN. 

lumbar  region,  tmd  to  tlie  wall  from  a  little  below  the  uinlnlicus. 
This  extent  of  adhesion  quite  accounted  for  the  fixed  Ftate  which  the 
tumor  liad  always  presented.  Upward  of  four  pints  of  a  dirty, 
black,  ])urulcnt-looking  fluid  were  removed,  the  incision  was  en- 
larged, and  with  uue  strong  pull  of  the  arm,  pushed  in  from  behind, 
the  adhesions  were  broken  up  and  the  tumor  dragged  out.  80  rap- 
idly was  blood  lost  from  huge,  torn  veins  in  the  capsule,  that  she 
became  faint.  The  left  ovary  only  could  be  included  in  the  wire 
lio-ature.  From  the  previous  elevation  of  the  cervix,  the  stump  was 
secured  in  the  lower  angle  of  the  wound  with  less  tension  than  in 
the  lirst  case.  This  part  of  the  operation  occupied  only  a  few  min- 
utes, but  it  was  upward  of  two  hours  ere  the  wound  was  closed. 
Much  trouble  arose  from  stopping  lileeding  in  the  torn  adhesions, 
more  especially  those  high  up  on  the  insides  of  the  ribs,  near  the 
posterior  margin  of  the  liver.  A  glass  drainage-tube  was  left  in, 
passing  to  the  bottom  of  the  pelvis.  The  patient  was  pulseless  when 
placed  in  bed.  This  was  an  anxious  operation  on  account  of  the 
unusual  loss  of  blood. 

It  is  unnecessary  to  give  details  of  the  slow  convalescence.  The 
tube  was  removed  on  the  fourth  day,  and  the  whole  amount  of  red 
sei-um  that  came  away  did  not  exceed  three  ounces.  This  could 
easily  have  been  absorbed.  The  pulse  had  fallen  to  below  100  by 
the  lifth  day,  and  there  was  scarcely  any  disturbance  of  the  tem- 
perature. There  was,  however,  much  flatulence  during  the  second 
and  third  weeks,  also  much  trouble  with  the  bowels,  and  at  one  time 
there  was  a  fear  of  obstructed  intestine.  It  was  thought — though 
there  w'as  no  evidence  of  this — that  there  might  have  been  some 
adhesion  at  the  angles  of  the  bowel,  caused  by  the  presence  of  the 
drainage-tube.  As  in  the  former  case,  the  slough  extended  far  be- 
yond the  wire,  and  a  largo  cavity  was  left  on  its  separation. 

Six  weeks  later  she  went  home.  I  saw  her  quite  recently.  She 
was  in  perfect  health,  and  had  been  so  ever  since  her  operation,  now 
nearly  ten  years  ago. 

The  application  of  electrolysis  to  the  treatment  of  fibroids  has 
been  so  thoroughly  elaborated  by  Prof.  George  J.  Engelmann,  M.  D., 
of  St.  Louis,  that  I  have  with  his  permission  given  here  a  few  cases 
from  his  work  on  that  snl)jcct : 

Uterine  Fibro-myoma  with  Menorrhagia,  Retro-uterine  Hematocele, 
and  Left  Cellulitis. — The  haemorrhagic  state  of  this  case,  the  existing 
inflammation,  which  was  active,  subacute,  contra-indicated  electrol- 
ysis or  negative  electro-puncture.  To  check  the  haemorrhage,  posi- 
tive electro-cauterization  was  resorted  to,  the  platinum  sound  con- 


FIBROMA  OF  THE   UTERUS.  395 

nccted  with  the  anode  in  the  uterus,  the  large  dispersing  cathode 
upon  the  abdomen.  At  the  lirst  sitting  a  current  of  fiO  milliauiperes 
was  used  for  eight  minutes,  no  stronger  current  being  admissible  on 
account  of  the  existing  inflammation.  The  effect  was  good,  haem- 
orrhage and  pain  lessened.  Two  days  later  the  treatment  was  re- 
peated, 100  milliamperes  used  for  six  minutes ;  bleeding,  which  had 
been  almost  constant,  was  stopped.  After  three  further  treatments 
upon  alternate  days,  the  menses  appeared :  previously  profuse,  now 
normal  in  quantity.  This  symptom  being  overcome,  the  inflamma- 
tory conditions  were  attacked  by  vagino-abdominal  galvanism ;  the 
negative  pole,  a  large  metallic  ball  covered  with  absorbent  cotton, 
moistened  in  warm  water  applied  per  vagina,  the  large  plate  in  con- 
nection with  the  positive  pole  upon  the  abdominal  surface  of  the 
exudation.  From  40  to  60  milliamperes  were  so  used,  serving  to 
relieve  the  pain.  Haemorrhage  and  excessive  suffering  being 
overcome,  the  patient  was  ordered  to  bed  at  her  home,  and  di- 
rected to  continue  the  use  of  poultices  and  hot-water  injections 
until  more  active  measures  could  be  taken  for  the  destruction  of  the 
tumor. 

Uterine  Fibro-myoma  (bilobar)  extending  to  one  finger's  breadth 
above  the  navel. 

First  tentative  treatment,  May  2d  :  negative  electro-puncture ; 
small  stylet  introduced  to  the  depth  of  3  centimetres ;  80  milliamperes 
for  five  minutes. 

Se^cond  puncture.  May  5th :  large  platinum  stylet  introduced  to 
the  depth  of  4  centimetres  ;  an  intensity  of  100  milliamperes  for  five 
minutes ;  no  pain  was  experienced  from  the  internal  electrode,  and 
the  abdominal  burning  diminished  greatly  toward  the  end  of  the 
sitting. 

Third  sitting,  after  an  easy  menstrual  period,  May  12th  :  80  mil- 
liamperes, six  minutes ;  highest  portion  of  the  tumor  3^  centimetres 
below  the  navel. 

Fourth  sitting,  May  24th :  60  milliamperes,  eight  minutes ;  large 
stylet  introduced  to  the  depth  of  7  centimetres ;  highest  portion  5 
centimetres  below  navel. 

May  31st,  notwithstanding  that  a  current  of  only  60  milliamperes 
had  been  applied  on  account  of  insufiicieucy  of  the  battery,  local  pain 
follow^ed,  the  tumor  enlarged  in  circumference,  extending  above  the 
navel,  became  tense,  swollen,  apparently  fluctuating ;  no  rise  of  pulse 
or  temperature.     Treatment  deferred. 

June  2d,  fifth  treatment :  50  milliamperes,  six  minutes ;  tumor 
harder,  less  elastic,  much  diminished. 


396  DISEASES  OF   WOMEN. 

June  7tli,  sixtli  treatment :  large  stylet,  8  centimetres,  60  milli- 
amperes,  seven  minutes. 

June  loth,  seventh  treatment :  00  milliamperes,  ten  minutes ; 
tumor  very  bard,  extending  half-way  to  umlnlicus ;  pelvis,  which 
had  at  first  been  abnost  full,  more  free ;  vagina,  which  had  been  a 
fan-like  expansion,  now  assuming  more  normal  proportions.  Ice-bag 
immediately  after  treatment,  since  it  had  answered  well  when  apj)lied 
during  the  apparently  inflammatory  enlargement.  The  patient  re- 
turned to  her  home  after  the  ninth  treatment  greatly  improved  in 
health,  functions  re-established,  the  tumor  reduced  very  much  in 
size.     Each  of  the  nine  sittings  had  lasted  from  five  to  ten  minutes. 

Uterine  Fibro-myoma. — General  debility,  scanty  menstruation. 
Patient  aged  thirty-two.  A  fibro-myoma,  similar  to  the  last,  filling 
the  pelvic  cavity,  its  left  half  extending  to  the  height  of  the  navel, 
the  right  an  inch  and  a  half  lower,  the  uterine  cavity  possessing  a 
depth  of  13  centimetres.  This  tumor,  which  had  been  first  noticed 
in  November,  1885,  had  been  rapidly  growing,  notwithstanding 
active  local  and  constitutional  treatment,  mainly  with  ergot,  at  the 
hands  of  one  of  our  ablest  gynecologists,  first  came  under  my  ob- 
servation March  9, 1886,  recommended  to  me  by  her  previous  attend- 
ant, my  esteemed  friend  Prof.  Boisliniere. 

April  28th.  first  tentative  treatment ;  the  puncture  made  with  a 
small  stylet ;  a  current  of  45  milliamperes  was  used  for  five  minutes. 
Treatment  was  continued  once  a  week,  the  puncture  hereafter  being 
made  with  a  large  platinum  stylet  through  the  cervical  tissue,  and 
the  prominent  vaginal  projections  of  both  right  and  left  masses, 
which  were  punctured  to  a  depth  of  from  7  to  8  centimetres.  For 
the  six  treatments  following  the  first,  a  current  of  from  100  to  110 
milliamperes  was  used ;  then  a  still  higher  intensity,  from  160  to 
200,  was  applied.  The  burning,  occasionally  intense,  oftea  decreased 
to  a  minimum  toward  the  end  of  tlie  sitting  (by  reason  of  the  anres- 
tlietic  effect  of  the  positive  pole),  the  punk-  and  chamois-covered 
plate  being  used,  leaving  the  abdomen,  after  its  removal,  sometimes 
slightly  reddened,  but  always  cool.  This  patient,  feeble,  subject  to 
fevers,  at  first  did  not  improve  constitutionally.  The  tumor,  after 
the  third  puncture,  was  3  centimetres  below  the  navel  on  the  left 
side,  4  on  the  right — the  pelvis  more  free,  a  most  decided  shrinkage, 
due,  I  presume,  in  part  to  the  powerful  contraction  caused  l)y  the 
high  intensity  used.  In  this  case  free  bleeding  followed  several  of 
the  a])])lications,  from  one  to  six  hours  after  treatment,  after  the 
fourth  puncture  ;  coming  at  one  time  when  still  on  the  table,  checked 
with  considerable  difticulty  by  iron  cotton  tampons.     By  June  2Sth 


FIBROMA   OF  THE   UTERUS.  397 

the  tumor  seemed  again  to  increase ;  her  general  condition  not  hav- 
ing improved,  menstruation  still  being  excessively  scant,  a  mere 
show,  1  endeavored  to  further  constitutional  improvement,  using  no 
internal  remxdies,  as  she  complained  of  her  stomach,  which  had 
been  ruined  bv  constant  but  ineffective  medication;  electrolysis  was 
stopjicd,  and  negative  electro-cauterization  resorted  to  for  the  ]3ur- 
pose  of  increasing  the  flow.  The  uterine  cavity  then  measured  11 
centimetres. 

July  1st,  negative  electro-cauterization  ;  100  milliamperes,  six 
minutes.  July  12th,  100  milliamperes,  eight  minutes.  July  16th, 
150  milliamperes,  ten  minutes,  no  discomfort  whatsoever  being  ex- 
perienced from  the  intrauterine  negative  pole. 

August  6th,  menses  free,  continuing  five  days ;  more  profuse  and 
better  than  ever  before  since  first  established ;  she  has  gained  three 
and  a  half  pounds  in  the  last  month ;  looks  much  better ;  feels  well. 
This  treatment  was  continued,  with  interruptions,  during  the  sum- 
mer ;  menses  more  free  than  they  had  been  for  years ;  her  general 
condition  much  improved.  No  medication  whatsoever  was  re- 
sorted to. 


i 


CHAPTER    XXIT. 

MALIGNANT   DISEASE    OF    THE    UTERUS. 

A  VERY  important,  and  a  very  frequent  class  of  diseases  is  tliat  in- 
cluded in  the  above  term ;  and  for  this,  if  for  no  other  reason,  must 
we  have  a  clear  notion  of  the  terminology  so  often  misapplied. 

Malignant  growths  are  those  which  tend  to  infiltrate  and  destroy 
adjacent  tissue,  to  recur  after  removal,  possibly  originate  remote 
secondary  neoplastic  formations,  and  which  cause  steady  deteriora- 
tion of  the  general  health  without  regard  to  location.  They  are 
not  necessarily  "  cancers." 

Cancer  is  an  "  atypical  epithelial  neoplasm,"  distinct  from 
growths  of  the  pure  connective-tissue  type.  Its  forms  are  few  and 
pretty  well  settled  and  agreed  upon.  The  tirst  is  scirrhus,  hard, 
chronic,  or  fibrous  cancer ;  the  second  is  soft,  acute,  mediiUary,  or 
encephaloid  cancer  ;  the  third  is  colloid,  "  gum,"  or  alveolar  cancer ; 
but  whether  epithelioma  is  a  fourth  variety  or  is  itself  a  distinct 
form  is  still  a  mooted  question. 

Epithelioma  is  often  intensely  malignant ;  and  the  term  "  can- 
croid "  is  a  safe  one  as  it  certainly  is  like  a  cancer. 

Another  vexed  question  is  whether  cancer  of  the  utenis  is  a  local 
exhibition  of  a  constitutional  malady,  or  is  at  first  local  and  only 
later  infects  the  system  generally. 

The  same  uterus  may  be  the  seat  of  several  varieties  of  carci- 
noma ;  or,  again,  the  neoplasm  may  change  from  one  form  into 
another  as  well  without,  as  after,  surgical  interference. 

Sarcomata  are  malignant  directly  in  proportion  to  the  lowness  of 
their  organization.     They  are  of  the  embryonal-tissue  type. 

CANCER  OF  THE  CERVIX. 

The  body  of  the  uterus  is  so  seldom  the  seat  of  carcinosis  that 
when  the  unqualified  phrase  "  cancer  of  the  uterus "   is  used,  it 


MALIGNANT  DISEASE  OF  THE   UTERUS.  399 

means  of  the  cervix.     Malignant  disease  of  the  corpus  will  be  con- 
sidered separately. 

Excepting  epithelioma,  scirrlms  is  the  most  frequent  variety, 
says  one  class  of  gynecologists ;  encephaloid,  says  the  other.  They 
are  both  right,  for  I  believe  the  initial  stage  to  be  nearly  always  the 
hard  carcinoma,  which  subsequently  becomes  soft  and  medullary  ; 
and  since  it  is  only  the  later  form  that  is  apt  to  produce  symptoms 
sufficiently  marked  for  the  patient  to  consult  a  physician,  this  may 
account  for  the  supposed  rarity  of  scirrhus,  as  compared  with  en- 
cephaloid cancer  of  the  uterus. 

With  this  idea  of  the  development  of  the  neoplasm  in  view  the 
pathology  will  be  given. 

Pathology.— One  lip  of  the  cervix  becomes  hard,  uneven,  and 
hypertrophied,  and  the  nodules,  which  (probably)  originate  in  the 
submucous  tissue,  subsequently  ulcerate  through  the  mucous  mem- 
brane, which  is  now  covered  with  vascular  vegetations,  especially 
near  the  orifice  ;  the  opposite  lip  suffers  an  identical  lesion,  the  cer- 
vical orifice  enlarges  and  now  the  whole  cervix  is  covered  with  veg- 
etations. 

The  cellular  tissue  of  the  vaginal  mucosa  just  beneath  this  fun- 
goid mass  which  projects  into  the  vagina,  becomes,  in  its  turn,  in- 
durated, uneven,  and  granulated,  while,  simultaneously,  the  muscu- 
lar coat  of  the  cervix  is  being  infiltrated  with  the  growth. 

The  mucous  ulceration  is  frequently  gangrenous,  and  a  fetid 
fluid,  containing  shreds  of  dead  connective  tissue  and  portions  of 
vessels  which  supplied  the  necrosed  part,  bathes  the  surface  at  the 
cervico-vaginal  junction  where  the  loss  of  continuity  is  best  marked ; 
and  thus  a  hob-nailed  or  fungating  mass  entirely  takes  the  place  of 
what  we  should  normally  feel  upon  a  vaginal  examination.  In  very 
rare  cases  the  carcinomatous  mass  is  removed  in  toto  as  a  gangrenous 
slough,  and  then  the  ulcerated  patch  that  remains  is  walled  in  by 
normal  tissue.     It  is  to  all  appearance,  a  phagedenic  ulcer. 

Microscopically,  a  section  of  scirrhus  shows  small  cavities  (alve- 
oli) surrounded  by  thick  fibrous  stroma,  and  in  the  alveoh  are  only 
a  few  polyhedral  cells. 

An  encephaloid  section  exhibits  a  delicate  and  scanty  frame- 
work surrounding  large  alveoli  which  are  crowded  with  cells  (many 
of  which  are  fatty)  in  a  milk-white  fluid,  the  "  cancer-juice."  The 
section  from  such  a  tumor  is  light  in  color  and  mottled.  In  the  ves- 
sels are  plugs  made  up  of  cancer-cells  and  fibrin ;  the  walls  of  these 
vessels  are  pigmented  and  fatty. 

Either  variety  is  melanotic,  when  the  blood   pigment   in  the 


4U0  DISEASES  OF  WOMEN. 

stroma  and  alveoli  is  so  rich  as  to  produce  a  deep  brown  or  black 
hue. 

Finally,  one  of  the  rarest  forms  of  carcinoma  uteri  is  colloid  can- 
cer ;  the  difference  between  it  and  encephaloid  (of  which  it  is  a 
modification)  is  that  the  cells  enlarge  and  are  tilled  with  colloid  ma- 
terial, the  alveoli  enlar<ije  also,  and  as  the  stroma  thins,  one  cavity 
communicates  with  another  so  that  anfractuous  spaces  are  formed 
tilled  with  a  transparent  gum  like  substance. 

The  pathological  effects  of  cancer  of  the  womb  are  many  and 
important.  It  may  extend  to,  and  jjerforate  tlirough  the  vesical 
wall ;  this  occurs  of tener  than  one  out  of  three  cases,  and  cystitis  al- 
ways precedes  the  rupture. 

Vesico- vaginal  hstulae  are  by  no  means  uncommon,  and  here  we 
shall  often  find  severe  gangrenous  processes  attending. 

Rectitis  may  be  excited  and  the  wall  of  the  rectum  be  perfo- 
rated. These  are  not  half  so  frequent  as  bladder  lesions.  When, 
however,  both  structures  are  opened  there  is  a  cloacal  intercomum- 
nication  of  vagina,  rectum,  and  bladder. 

When  stenosis  of  the  ureters  results  either  from  external  press- 
ure or  from  thickening  of  their  walls,  we  will  find  the  kidney  anae- 
mic and  full  of  urine  (hydronephrosis). 

The  cellular  tissue  of  the  broad  ligament  and  iliac  fossce  is  infil- 
trated, and,  later,  undergoes  purulent  infiltration,  frequently  induc- 
ing peritonitis,  while  the  vessels  and  lymphatics  leading  to  such 
purulent  collections  are  the  seat  of  carcinomatous  inflammation. 

The  peritonaeum  of  Douglas's  cul-de-sac  is  pushed  upward  and 
pseudo-membranes  inclose  the  uterus  both  anteriorly  and  poste- 
riorly. 

The  subperitoneal  connective  tissue  of  the  ti-ue  pehns  is  thick, 
hard,  and  adherent  to  the  bones  ;  it  may  press  on,  and  cause  fatty 
changes  in  the  sciatic  and  pelvic  nerves. 

The  body  of  the  uteiiis  may  be  infiltrated,  the  organ  being  as 
large  as  when  pregnant.  Its  walls  may  measure  one  and  one  half 
.  inch  in  thickness. 

The  tubes  are  rarely  involved ;  and  if  carcinoma  be-located  at 
first  solely  in  the  cervix  the  ovaries  always  escape. 

When  cancer  proKferates  downward  in  the  vaginal  walls  it  forms 
numerous  nodes,  as  far  as  the  introitus  vaginae,  so  that  a  physical 
examination  will  become  difficult  or  impossible. 


MALIGNANT  DISEASE  OF  THE   UTERUS.  401 


EPITHELIOMA   OF   THE   CERVIX. 

Cancroid,  formerly  called  rodent  ulcer  of  the  cervix,  is  not  so 
malignant  as  scirrlins  or  encepbaloid  carcinoma.  It  seems  to  be  of 
a  more  local  character  than  the  other  neoplasms  of  this  group. 

It  ajDpears  in  one  of  two  fonns — as  pavement-celled  epithelioma 
or  as  cylindrical-celled  epithelioma.  Excepting  colloid  cancer,  this 
last  is  the  rarest  form  of  uterine  neoplasm. 

Pathology. — Pavement-celled  epithelioma  begins  in  the  epithelia 
of  the  vaginal  portion  of  the  cervix,  the  tumor  formed  being  waxy, 
slightly  vascular  in  spots,  and  dry  on  its  surface.  The  mass  is  fria- 
ble ("  fragile  cancer "),  and  on  pressure  we  can  squeeze  out  white 
worm-like  plugs,  comj30sed  of  epithelial  cells. 

I  have  occasionally  found  this  variety  to  begin  within  the  cervical 
canal,  and  extend  outward  (not  downward),  so  that  on  exploration 
the  mass  could  be  scooped  out,  leaving  the  cervix  a  mere  shell,  its 
exterior  or  vaginal  portion  showing  few  if  any  signs  of  new  growth. 

The  tumor  is  lobulated,  and,  when  the  lobules  compress  the  ves- 
sels, gangrene  results,  and  all  that  part  of  the  cei'vix  that  is  carcinom- 
atous may  di'op  off,  or  a  deep,  crater-like  ulcer  is  excavated  whose 
edges  are  always  nodular ;  hence  the  term  "  ulcerating  epithelioma." 

Squamous  epithelioma  extends  to  the  body  and  fundus,  but  in 
general  its  spread  is  limited  by  the  nearest  chain  of  lymphatics. 

Microscopically,  a  tubular  structure  is  often  seen,  the  tubes  being 
surrounded  b}^  a  fibrous  material,  and  probably  originating  from  the 
culs-de  sac  of  the  cervical  glands. 

The  appearance  of  the  section  has  given  the  name  "  cystic  epi- 
thelioma "  to  it.  When  the  tumors  are  crowded  with  lobulated  nests 
of  cells,  connected  together  with  epithelial  bands,  the  centers  are 
filled  either  with  colloid  matter  or  a  hard  mass  resembling  ordinary 
callous  (such  as  that  on  the  hand  or  foot). 

Cylinder  celled  epithelioma  originates  as  a  pedunculated  or  ses- 
sile vascular  wart;  and,  although  the  dendritic  tumor  begins  in  a 
single  spot,  it  tends  toward  the  vagina  in  its  growth,  and  spreads 
downward  as  the  so-called  "  caulifiower  excrescence,"  often  as  large 
as  a  hen's  egg,  and  not  rarely  completely  filling  the  vagina. 

The  glands  are  so  distended  that  the  French  pathologists  call  this 
"  adeno-carcinoma." 

At  first  the  cylinder  cells  of  the  cervical  mucosa  form  a  soft  mass, 
with  a  milky  juice ;  thus  it  is  hard  to  differentiate  it  from  encepb- 
aloid except  by  the  aid  of  the  microscope. 

Non-malignant  papillomata  also  resemble  these  vegetating  epi- 
27  "" 


402  DISEASES   OF   WOifEN. 

tlieliomata,  and,  without  a  luicroscropical  examination,  wlictLer  a 
caulitiower  excrescence  is  or  is  not  malignant  can  not  he  determined. 
With  such  an  examination  the  non-mali^rnant  is  seen  to  lie  ujxm 
healthy  submucous  tissue,  the  malignant  ujDon  unhealthy ;  the  nun- 
malignant  is  a  simple  anastomosing  framework,  while  the  malignant 
growth  has  an  alveolar  arrangement  with  cell-nests. 

This  form  of  cancroid  invariably  ulcerates ;  and,  though  occur- 
ring late  in  the  disease,  this  process  is  rapid  and  destructive,  larg* 
vessels  often  being  eroded. 

Microscopically,  it  consists  of  numerous  long  stems,  all  intercon- 
nected, each  stem  having  at  its  center  a  vascular  loop,  the  exterior 
covering  being  long  cylinder  cells  ;  thus  it  is  like  an  intestinal  villus, 
only  longer,  and  the  numerous  vessels  among  the  masses  of  cells  per- 
mit serum  to  ooze  through  their  walls,  and  this  is  the  chief  source 
of  the  watery  discharge  of  this  disease. 

The  points  of  secondary  invasion  are  many ;  the  bones,  lungs, 
liver,  bladder,  rectum,  pelvic  nerves,  adjacent  lymphatics,  and  the 
uterus  have  been  the  loci  of  later  malignant  growth,  and  in  the 
uterus  it  occupies  the  tibro-uiuscular  structure  as  numerous  and  par- 
tially distinct  nodules. 

Sijinptomatology . — Malignant  disease  of  the  womb  runs  no  typi- 
cal course.  As  with  cancer  elsewhere,  so  here  there  is  a  stage  where 
a  tumor  is  forming,  and  a  stage  where  it  ulcerates. 

During  the  first  of.  these  stages  the  amount  of  pain,  the  leucor- 
rhcea,  and  h[eraorrhage  are  so  slight  that  few  patients  will  consult 
the  physician  about  them.  And,  as  I  have  said,  it  is  probably  for 
this  reason  that  scirrhus  is  considered  a  rare  form  of  cancer.  And 
let  me  say  at  the  very  outset  that  the  lancinating  pain  so  often  men- 
tioned all  through  our  literature  as  strongly  symptomatic  of  cai'ci- 
noma  uteri  is  exceptionally  met  with  in  this  disease. 

A  discharge  is  the  earliest  sj-mptom  in  the  majority  of  cases. 
This  discharge  may  be  bloody,  watery,  or  leucorrheal.  As  a  rule 
it  assumes  the  character  of  an  intense  menorrhagia,  the  patient  also 
bleeding  between  the  menstrual  epochs  either  spontaneously  or  from 
sudden  exercise  or  coition.  Some  women  will  state  that  although 
their  change  of  life  occurred  a  year  or  so  ago,  that  now  they  have 
"  commenced  again." 

The  bloody  discharge  may  or  may  not  be  fetid  and  gmmous,  but 
the  organic  matter  which  forms  the  gnimous  discharge,  and  which 
is  continually  sloughing  away  and  passing  out  of  the  genitals,  very 
seldom  causes  any  septicemia.  Besides,  the  lymphatics  are  not  here 
abundant  in  the  immediate  neighborhood  of  the  cancerous  tumor. 


MALIGNANT  DISEASE   OF  THE   UTERUS.  403 

Watery  discliargcs  consist  chiefly  of  the  clear  serum  of  the  blood ; 
they  are  usually  odorless  at  first,  but  soon  become  mingled  with 
ulcerative  debris,  and  are  peculiarly  foul  smelling.  They  are  seldom 
or  never  free  from  admixtm'e  of  blood,  and  there  are  very  few  who 
will  not  give  "  bloody  water  "  as  one  of  their  chief  symptoms. 

The  watery  flux  is  almost  characteristic  of  the  cauliflower  excres- 
cence. 

In  many  cases  the  discharge  is  simply  leucorrheal  up  to  the  time 
of  ulceration  of  the  cancer,  after  which  the  fetid  "  cancer  smell " 
and  molecular  masses  from  the  growth  indicate  the  true  cause  of  the 
discharge. 

A  sudden  bright  hseraorrhage  indicates  that  a  medium-sized  ar- 
tery has  been  opeued. 

The  more  rapidly  the  neoplasm  forms,  and  the  more  extensively 
it  ulcerates,  the  more  profuse  and  fetid  will  be  the  discharge. 

Excoriations,  erosions,  erythema,  vaginitis,  vaginismus,  intense 
praritus,  and  similar  conditions  may  result  from  the  passage  of  these 
discharges  through  and  over  the  genitals. 

Pain  is  never  so  prominent  a  symptom  as  the  discharge,  and, 
according  to  some,  never  a  symptom  so  long  as  the  cervix  alone  is 
the  seat  of  malignant  growth.  The  character  of  the  pain  is  described 
differently  by  different  j)atients,  as  dull,  boring,  gnawing,  shooting, 
and  stabbing. 

The  pain  shoots  in  the  direction  of  the  parts  supplied  by  branches 
of  the  nerve  whose  main  trunk  is  pressed  upon.  The  back,  pelvis, 
and  thighs  are  the  chief  regions  of  this  kind  of  pain. 

The  pain  is  more  acute  when  the  terminal  nervous  branches  are 
involved  than  when  the  trunk  alone  is  compressed ;  and  it  is,  again, 
more  severe  when  there  is  a  large  amount  of  neoplastic  tissue  formed 
than  when  ulceration  is  extensive. 

The  pain  of  peritonitis,  which  may  be  lighted  up  by  the  gro\vth, 
has  characters  peculiar  to  itself 

The  amount  of  tenderness  is  not  always  in  proportion  to  the 
pain. 

Pain  on  motion  and  from  coition  (dyspareunia)  is  experienced 
almost  from  the  onset  in  neoplasms  of  the  cervix ;  later  on,  defeca- 
tion and  urination  may  produce  intolerable  suffering.  Pain  as  a 
symptom  may  be  absent  throughout  the  disease,  and  the  patient  only 
experience  weight  and  bearing  down. 

As  the  disease  progresses,  the  patient  first  loses  strength,  appe- 
tite, and  all  cheerfulness  of  disposition,  emaciation  following  later 
on.    The  face  assumes  an  earthy  green,  or,  toward  the  end,  a  bronzed 


404 


DISEASES   OF  WOMEN. 


hue,  and  tlio  temperature  may  be  slightly  subnormal.    There  is  som- 
uolenee  and  headache,  hut  echimpsia  is  iiifre(jueiit. 

Tlie  bowels  are  constipated,  as  a  rule,  but  irritation  or  actual 
cancer  of  the  rectum  may  cause  profuse  and  exhaustive  diarrhifa; 
hiiimorrhoids  are  common.  Cystitis,  strangury,  and  retention  or  in- 
continence are  not  infrequent  bladder  symptoms. 

When  fistulie  form,  they  give  rise  to  their  usual  symptoms.  In 
one  case  the  first,  and,  indeed,  the  sym])tom  on  which  the  diagnosis 
was  made,  was  a  How  of  urine  from  the  region  of  the  cervix. 

The  breasts  are  frequently  the  seat  of  sympathetic  pain.    Toward 

the  close  of  the  disease  there 
is  usually  a  slight  febrile  move- 
ment in  contrast  with  the  tem- 
perature in  the  early  stages  of 
the  disease. 

Physical  Signs. — Scirrhus 
carcinoma  gives  a  hard,  hob- 
nailed or  nodular  feel  to  the 
finger  during  the  earliest  sta- 
ges, and  the  mucosa  seems  to 
be  immovably  fixed  on  the  sub- 
jacent connective  tissue,  a  con- 
dition not  met  with  except  in 
malignant  growths. 

When  any  cancer  has  ul- 
cerated (the  usual  time  when 
the  physician  sees  it),  the  fin- 
ger meets  a  friable,  irregular  mass,  which  bleeds  upon  the  slightest 
provocation,  and  wliich  is  surrounded  l)y  a  tough,  unyielding,  irreg- 
ular zone  of  infiltrated  tissue.  If  readied,  the  lips  of  the  cervix  are 
felt  to  be  uneven,  thick,  and  spreading  downward  like  a  mushroom. 
Palpation  may  further  re\'eal  in  many  cases  fistula?,  innnobility 
of  the  womb,  changes  in  the  size  and  position,  and  infiltrations  and 
indurations  in  the  neighborhood. 

In  scirrhus  the  womb  is  felt  to  be  low  down  in  the  pelvis. 
The  bowels  may  have  been  so  constipated  that  the  physician 
examines  for  stricture  of  the  rectum  before  searching  for  anything 
else ;  but  in  doing  this  he  will  directly  suspect  the  true  state  of 
affairs,  and  especially  so  if  the  pelvic  cellular  tissue  or  neighboring 
glands  be  involved. 

A  second  physical  sign,  Avhich  is  supposed  by  some  to  be  diag- 
nostic, is  that  a  sponge  tent  or  uterine  dilator  fails  to  dilate  a  cervix 


Fig.  184.— Cancer  of  both  lips  (Winckel). 


MALIGNANT  DISEASE   OF  THE   UTERUS.  405 

suffering  from  malignant  disease,  whereas  in  all  other  neoplasms  dila- 
tion will  quickly  and  easily  follow  its  introduction. 

A  tliird  physical  sign  is  indescribable ;  it  is  the  odor  that  the 
finger  has  after  such  an  examination — an  odor  produced  by  nothing 
else  but  cancer. 

A  fourth  means  of  physical  diagnosis  is  the  speculum,  by  the 
use  of  which  we  see  what  has  already  been  described  under  the  head 
of  pathology.  Commencing  scirrhus  is  accompanied  by  a  deep  pur- 
plish or  livid  hue  of  the  entire  cervix,  and  enlarged  vessels  are  seen 
to  ramify  about  these  nodules. 

The  extent  of  the  growth  can  only  be  accurately  appreciated  by 
this  means  of  examination.  Epithelioma  of  the  cervical  cavity  is 
often  diagnosticated  solely  by  the  use  of  the  speculum  and  curette 
or  probe. 

Lastly,  the  microscope  may  be  used  not  only  to  diagnosticate  the 
presence  or  absence  of  carcinoma,  but  to  decide  which  variety  we 
have  to  deal  with.  It  should  be  stated  here  that  malignancy  can 
not  be  decided  by  the  microscope,  since  it  is  a  clinical  property. 

The  microscopical  appearances  of  each  form  have  already  been 
described. 

Diagnosis. — Before  treating  of  the  points  in  which  cancer  and 
other  lesions  of  the  uterus  differ,  it  is  necessary  to  mention  the  char- 
acters that  especially  distinguish  one  form  of  carcinoma  from  an- 
other. 

Scirrhus  gives  a  nodular,  hard  sensation  on  palpation,  immobility 
of  mucosa  upon  sub-mucosa,  prevents  cervical  dilatation  on  using 
the  sponge  tent  or  the  uterine  dilator,  showing  less  of  elasticity  in 
the  tissues,  and  the  discharge  is  scanty. 

In  medullary  cancer  the  grumous  discharge  containing  molecu- 
lar debris  is  the  prominent  symptom.  The  course  of  this  cancer  is 
the  most  acute  of  all.  The  brittle,  crumbling,  ulcerated  mass  is  pe- 
culiar to  this  form.     The  uterus  is  usually  fixed  and  immovable. 

Epithelioma  is  accompanied  by  a  more  profuse  watery  discharge 
than  any  other  variety ;  and  on  palpation  the  finger  meets,  often, 
the  characteristic  cauliflower-like  mass.  The  uterus  even  late  in  the 
disease  suffers  no  fixation,  and  may  be  moved  without  pain.  This 
variety  seems  more  local  than  the  preceding. 

In  all  instances  when  cancer  is  diagnosticated  a  microscopical  ex- 
amination will  determine  what  variety  we  are  dealing  with  ;  and  to 
this  end  a  piece  of  the  tumor  may  be  removed  by  the  curette. 

There  are  numberless  conditions  with  which  cancer  in  general 
may  be  confounded  ;  the  chief  of  these  are  : 


406  DISEASES   OF  WOMEN. 

Sloughing  Myomata  or  Fibrous  Polypi. — Tliesemay,  eitlierof  them, 
siniulatL'  caiicur;  hut  they  will  he  attended  hy  fever  wliieh  is  ahsent 
in  cancer,  and  there  will  he  in  the  discharj^es  shreds  of  the  normal 
uterine  tissue,  while  in  cancer  discharges,  epithelial  cells  will  he 
prominent.  Frequent  wasliings  control  the  former  while  cancer  re- 
mains unmoditied  therehv. 

Syphilitic  TJlceration, — This  not  only  resembles  cancer  hut  may 
even  i)roduce  vesico-recto-vaginal  tistulai.  Here  the  history,  the 
age  of  the  patient,  the  effects  of  local  and  constitutional  treatment, 
the  discharge,  and  an  examination  of  a  small  bit  of  the  tumor,  \\ill 
soon  allow  a  diagnosis  to  be  reached. 

Condylomata. — These  will  not  long  be  mistaken  for  cancer. 

Erosions. — These  are  numerous  ;  but  non-malignant  erosions  oc- 
cur in  younger  patients,  produce  no  constitutional  symptoms,  leave 
no  portion  of  the  cerNdx  intact,  are  attended  with  large,  gajnng  fis- 
sures and,  on  inspection  by  means  of  the  speculum,  large  ovula  Xa- 
bothi  are  seen.  The  discharge  does  not  have  the  cancerous  odor  in 
benign  erosions. 

Diphtheritic  and  Other  Intense  Inflammations  of  the  Mucosa. — These 
as  well  as  retained  portions  of  the  membranes  or  placenta,  have 
been  mistaken  for  cancer ;  here  again  the  liistory,  age,  and  the  use 
of  the  speculum  will  decide. 

Benign  Papillomata. — These  are  so  small  in  size  that  only  for  a 
sLort  time  will  they  be  mistaken  for  cauliflower  excrescence.  At 
all  events  the  microscope  will  decide. 

The  points  in  connection  with  cancer  of  the  body  and  cancer  of 
the  cervix  are  considered  hereafter. 

Prognosis. — It  is  needless  to  say  that  the  invariable  tendency  of 
malignant  uterine  disease  is  toward  death.  The  chief  question  in 
prognosis  therefore  is  of  the  duration  of  life.  There  are  uo  hard 
and  fast  rules  for  the  expectation  of  life,  nor  do  my  o\vn  statistics 
or  those  of  others  afford  definite  statements. 

Three  months  and  three  years  are  the  extreme  figures  given. 

In  general  it  may  be  stated  that,  after  the  first  marked  syra])tom 
(some  discliarge),  the  patients  live  a  year,  except  those  who  have 
epitlielioma  or  cancroid  ;  these,  as  a  rule,  have  eighteen  months  of 
life  before  them. 

Xever  make  a  prognosis  immediately  after  diagnosticating  can- 
cer, but  wait  until  the  disease  pronounces  itself  a  slow  or  rapid,  an 
uncomplicated  or  a  complicated,  a  localized  or  an  extending  process. 

Among  the  complications  are  hydronephrosis  (see  pathology), 
and,  consequently,  uraemia,  cellulitis,  and  peritonitis,  and,  less  fre- 


MALIGNANT   DISEASE   OF   THE    UTERUS.  407 

quently,  septicaemia,  phlebitis  witli  venous  thrombosis,  embolism, 
and  caucer  in  adjacent  tissues  and  distant  organs,  the  liver  es])ecially. 

Death  may  result  from  simple  exhaustion  (cancerous  marasmus), 
or  from  ha3morrhagc  when  a  large  vessel  is  opened,  or  from  rupt- 
ure of  the  uterus  (rare),  or  from  any  of  the  above-named  complica- 
tions. 

Death  is  sometimes  delayed  and  torturing,  and  in  the  face  of  its 
being  inevitable  it  often  seems  as  though  it  were  a  mercy  to  hasten  it. 

Etiolo(jij. — Until  puberty  the  death-rate  from  cancer  is  the  same 
in  both  sexes ;  from  this  period  both  frequency  and  death-rate  stead- 
ily increase  in  the  female  up  to,  and  a  little  after,  the  menopause,  at 
which  2^eriod  the  difference  in  rate  between  the  sexes  is  most  marked. 
After  the  age  of  fifty  there  is  a  tendency  for  cancer  to  aj^j^ear 
equally  often  in  both  sexes. 

There  is  no  doubt  but  that  there  is  such  a  condition  as  a  predispo- 
sition to  malignant  disease  ;  but  to  what  extent  this  can  be  inherited 
or  not,  is  not  yet  determined.  It  is  well  known,  however,  that  cer- 
tain peculiarities  of  organization  predispose  to  malignant  disease. 
Among  these  is  the  cardio-vascular  hypoplasia  (Virchow),  where  the 
pulmonary  arteries  are  undersized,  and  which  occurs  often  with  the 
phlegmatic  temperament,  characterized  by  an  abundant  adipose-tis- 
sue and  an  appearance  of  health,  w^hich  is  an  appearance  and  noth- 
ing else. 

Great  differences  are  met  with  in  authorities  as  to  the  frequency 
of  cancer ;  reliable  statistics,  however,  tell  us  that  the  uterus  was  at- 
tacked in  three  thousand  cases  out  of  a  total  of  sixty-one  thousand 
seven  hundred  and  fifteen  cases  of  carcinoma  (anywhere  in  the 
body)  in  females.  The  same  also  afford  us  proof  that  the  uterus  is 
cancerous  three  times  as  often  as  any  other  female  organ. 

Heredity  has  an  undoubted  influence ;  I  have  gathered  the  sta- 
tistics of  many  thousand  cases,  and  find  that  an  inherited  taint  can 
be  traced  in  thirteen  per  cent  of  all  cases  on  an  average. 

Age  is  the  most  potent  factor  in  the  etiology.  Before  puberty, 
indeed  before  the  age  of  twenty,  cancer  is  unknown  or  phenomenal. 
I  have  seen  two  cases — both  ending  fatally — M'here  the  patients 
were  in  their-  twenty-seventh  and  twenty-eighth  year,  respectively ; 
and  the  sister  of  the  last  named  died  of  cancer  of  the  uterus  in  her 
thirty-first  year. 

The  ten  years  following  the  menopause  (forty  to  fifty)  is  the 
period  of  carcinoma  uteri :  the  decade  following  this  is  the  next 
most  eventful  j^eriod,  and  third  in  order  stand  the  ten  yeai's  preced- 
ing the  climacteric. 


408  DISEASES   OF  WOMEN. 

Race  seems  to  luivc  little  or  no  intluence.  Perhaps  it  is  pecul- 
iar to  my  practice,  yet  I  have  seen  more  cases  of  carcinoma  uteri 
among  Germans  than  in  any  other  nationality. 

There  is  more  than  an  accidental  agreement  l>et\veen  cancer  and 
the  number  of  children  born  ;  for  it  \nll  be  found  that  patients  with 
cancer  of  the  uterus  will  average  one  third  more  children  than 
women  free  from  malignant  disease  of  the  womb ;  indeed  every 
case  of  carcinoma  uteri  will  average  live  children,  a  large  family 
at  the  present  time. 

Prolonged  lactation,  anti-hygienic  surroundings,  poor  or  improper 
food,  exhausting  diseases,  grief  and  anxiety,  all  are  more  apt  to  be 
accompanied  by  cancer  than  an  opposite  condition  of  afiairs  ;  never- 
theless, seventy-five  per  cent  of  cases  will  give  a  history  of  good 
health  up  to  the  development  of  this  neoplasm. 

It  is  quite  certain  that  laceration  or  erosion  of  the  cervix  has  a 
causative  intluence  upon  cancroid ;  hence  in  suspected  epithelioma 
the  previous  history  must  always  be  elicited.  I  do  not  mean  that 
laceration  will  cause  it ;  but  with  a  latent  tendency,  an  erosion  or 
laceration  will  often  determine  the  precise  point  of  eruption  of  the 
disease. 

Treatment. — This  may  be  divided  into  constitutional  and  local ; 
and  the  local  treatment  consists  in  («),  topical  applications,  and  \J)\ 
operative  procedures. 

Constitutional  treatment  is  always  in  order,  and  is  always  bene- 
ficial, but  operative  treatment  demands  the  highest  judgment ;  used 
in  season,  surgical  means  may  eradicate  a  growth  that  never  reap- 
pears ;  used  when  any  tissue  or  part  other  than  the  uterus  has  become 
infected,  an  operation  is  useless  for  cure,  and  may,  indeed,  hasten 
the  fatal  termination. 

But,  be  it  understood,  there  is  only  one  means  of  actually  treat- 
ing a  patient  with  cancer,  and  that  is  to  operate  surgically,  not  merely 
to  nurse  her. 

Hgemorrhage  demands  prompt  treatment  on  account  of  the  ex- 
haustion it  induces.  Astringent  injections — hot  better  than  cold — 
plugging  of  the  vagina  with  small  pieces  of  ice,  or,  rarely,  plugs 
soaked  in  perchloride  of  iron,  may  be  used.  Tannic  acid,  rhatany, 
catechu,  perchloride  of  iron,  or  ergot  by  the  mouth  or  ergotine 
hypodermically  I  consider  as  inefficient,  and  are  only  mentioned  here 
to  be  condemned.     They  are  too  frequently  employed  in  practice. 

Rest,  especially  dunng  menstruation,  freedom  from  mental  shock 
of  any  sort,  and  cessation  of  intercourse  should  be  enjoined  to  pre- 
vent haemorrhage. 


MALIGNANT  DISEASE   OF  THE   UTERUS.  409 

Pain  finally  becomes  intolerable.  What  shall  be  given?  The 
easiest  way  to  quell  this  symptom  is  by  filling  the  patient  with  oi)ium 
or  morphine,  the  latter  given  hypodermically. 

Hydrate  of  chloral,  while  producing  a  more  natural  sleep  than 
opium,  does  not  seem  to  control  the  pain  so  well.  Cannabis  Indica 
and  hyoscyamus  are  highly  thought  of  by  the  French ;  also  vaginal 
pessaries  of  iodoform  (fifteen  grains).  The  hydrochlorate  of  cocaine 
is  an  efficient  local  and  general  remedy  for  pain. 

The  discharge  is  offensive,  and  the  patients  wish  its  fetor  de- 
stroyed before  demanding  treatment  for  almost  any  other  symptom. 

Condy's  fluid,  Labarraque's  solution,  carbolic  acid,  and  its  allies 
(thymol,  phenol,  etc.),  bromine,  lead  acetate,  or  iodine — any  of  these 
will  act  antiseptically,  and  will  in  part  deodorize  the  discharge.  At 
the  same  time  the  amount  of  the  discharge  can  be  diminished  by 
any  astringent  injection,  such  as  alum,  iron,  zinc,  lead,  or  copper, 
but  tannic  acid  seems  to  have  a  specially  favorable  action  upon  the 
flux  from  cauliflower  excrescences. 

The  diet  should  be  as  simple  as  possible,  yet  composed  of  food 
in  which  there  is  a  minimum  of  volume  and  a  maximum  of  nutri- 
ment. A  milk-diet  is  known  to  be  so  beneficial  that  the  laity  regard 
it  as  a  "  cancer  cure." 

A  moderate  amount  of  alcohol  should  be  taken  daily  with  the 
meals. 

JSText  in  importance  to  diet  is  the  mental  condition.  The  sur- 
roundings should  be  as  pleasant  as  possible.  The  prognosis  and  diag- 
nosis need  only  be  known  to  the  immediate  friends. 

Finally,  certain  symptoms,  such  as  peritonitis,  ulcerations,  and 
erosions  of  the  genitals,  may  call  for  treatment,  which  in  no  respect 
differs  from  that  in  non-cancerous  cases. 

In  the  local  treatment  of  carcinoma  of  the  cervix  the  application 
of  caustics  is  one  of  the  first  things  tried  by  the  inexperienced ;  and 
it  is  the  use  of  caustics  for  cancer  anywhere  that  has  become  the 
pre-eminent  means  in  the  hands  of  the  unprincipled. 

Pure  nitric  acid  removes  by  a  slough  extensive  portions  of  the 
diseased  tissue,  and  simultaneously  stops  hcemorrhage.  The  cervix 
should  be  washed  and  dried  immediately  before,  and  washed  again 
immediately  after  the  operation. 

Chromic  acid,  bromine  solutions,  acetic  acid,  perchloride  of  iron, 
and  even  gastric  juice  have  been  employed  as  caustics,  and  of  this 
group  I  prefer  the  first  named. 

Among  the  many  remedies  from  which  special  benefits  are  said 
to  accrue  in  the  treatment  of  cancer  is  the  milk  of  aveloz.     In  the 


410  DISEASES  OF  WOMEN. 

"Xew  York  Medical  Record,"  of  July  11,  1SS7,  is  a  report  on  this 
driiir,  made  bv  Dr.  James  B.  Hunter,  from  which  I  make  the  iiA- 
lowing  abstract : 

"  The  milk  of  aveloz  is  the  product  of  a  i)lant  growing  in  IJrazil, 
one  of  the  Jiuj^/io/'hiarca:,  many  varieties  of  which  are  well  known 
for  their  irritant  and  acrid  juices.  Dr.  Hunter  had  not  been  able, 
from  any  botanical  works  at  his  dis]:)osal,  to  ascertain  exactly  the 
position  of  the  plant  furnishing  the  juice  known  as  the  milk  of  aveloz, 
but  it  appeared  to  be  closely  allied  to  the  Ilura  crepitans^  the  milk  of 
which  is  described  by  the  older  botanists  as  possessing  extraordinary 
properties  as  an  irritant. 

"  Boussingault  made  an  examination  of  some  of  the  juice,  and 
was  attacked,  he  says,  with  a  severe  form  of  erysipelas.  The  courier 
who  brought  the  juice,  as  well  as  the  inhabitants  of  the  house  in 
which  he  spent  the  night  on  his  way,  were  also  attacked  with  severe 
inflammation  of  the  skin.  Another  species  of  the  same  family  grow- 
ing in  Brazil  is  the  Ilippomane  mancinella,  or  manchineel  tree, 
about  which  there  are  fabulous  accounts,  as  that  it  is  fatal  to  life  to 
sleep  beneath  its  shade.  It  is  true,  however,  that  a  di'op  of  the  juice 
of  that  tree  applied  to  the  skin  will  quickly  raise  a  blister  full  of 
serum.  It  is  not  surprising,  therefore,  that  the  milk  of  one  of  the 
Ei(,j>horhia  family  should  be  possessed  of  very  active  properties. 

"  Several  years  ago  a  small  quantity  of  the  milk  of  aveloz  was 
sent  from  Brazil  to  the  autborities  at  Washington,  and  distributed 
for  trial.  Then  for  a  time  none  could  be  obtained.  Later  it  was 
to  be  purchased  of  a  gentlemen  in  this  city — John  T.  Kirby,  IG 
Beaver  Street.  The  depot  for  its  sale  is  in  Pernambuco,  the  juice 
being  collected  chiefly  in  the  pro\'ince  of  that  name.  The  prepara- 
tion is  said  to  be  patented  by  the  Government  of  Brazil,  and  its  use 
is  indorsed  by  the  Central  Board  of  Health  of  Eio  de  Janeiro. 

"Two  preparations  are  furnished,  one  of  which  is  recommended 
for  open  ulcers,  and  the  other  for  cases  of  cancer  in  its  early  stages. 
The  principal  or  only  appreciable  difference  appears  to  be  in  the 
degree  of  inspissatiou. 

"  The  method  of  using  the  drug  advised  is,  that  the  affected  sur- 
face be  thoroughly  cleaned  with  a  carbolic  lotion,  and  dried.  The 
juice  is  then  applied  freely  with  a  soft  brush,  retained  in  place 
by  lint  or  cotton,  and  covered  with  light  rubber  or  gutta-perclia  tis- 
sue. The  purpose  of  the  application  is  to  produce  the  effect  of  a 
caustic.  Special  care  is  necessary  to  prevent  contact  with  sound  tis- 
sues, as  it  is  extremely  irritating.  The  application  is  repeated  every 
three  or  six  days,  according  to  the  condition.    Dr.  Hunter's  experience 


MALIGNANT  DISEASE   OF  TOE   UTERUS.  411 

had  been  confined  to  cases  of  epithelioma  of  the  cervix.  He  first 
alhidcd  l)rieflj  to  the  experience  of  others.  Its  application  to  dis- 
ease of  the  breast  is  said  to  be  very  jDainfuh  There  is  not  usually 
much  pain  in  its  use  on  the  cervix  uteri." 

During  the  past  three  years  Dr.  Hunter  has  applied  the  milk  of 
aveloz  in  many  cases  of  epithelioma  of  the  cervix,  and,  though  its 
effect  had  often  been  negative,  in  a  certain  number  it  had  produced 
results  that  he  had  not  obtained  by  any  other  means.  In  cases  of 
spongy,  easily  disintegrated  crevices,  it  had  left  a  better  surface  than 
nitric  or  chromic  acids,  or  than  the  actual  cautery.  It  had  also 
seemed  to  him  that  the  recurrence  was  delayed  longer  than  after  the 
ordinary  caustics.  He  had  confined  its  use  to  cases  where  the  knife 
was  not  applicable,  or  where  operation  was  not  allowed.  In  some 
cases  he  had  been  surprised  at  the  comparatively  healthy  condition 
of  the  surface  remaining  after  the  eschar  came  away,  and  sui'prised 
also  at  the  long  interval  that  elapsed  before  there  was  fresh  breaking 
down. 

One  of  the  effects  of  a  free  application  of  the  juice  to  a  diseased 
surface  is  to  promote  a  copious  serous  discharge,  thus  depleting  the 
congested  vessels.  In  some  cases  a  marked  difference  has  been  ef- 
fected in  the  character  of  the  discharge,  which  has  become  and  re- 
mained for  a  long  time  almost  inoffensive. 

Cases  which  the  doctor  related  illustrated  the  treatment  and  its 
results,  which  he  described  as  follows  :  "  All  that  could  be  said  was, 
that  they  were  in  some  respects  better,  as  to  the  arrest  of  the  disease 
and  as  to  the  comfort  of  the  patients  during  its  progress,  than  those 
afforded  by  many  of  the  usual  methods.  As  far  as  he  could  judge 
at  present,  he  should  not  use  the  aveloz  with  any  expectation  of 
effecting  a  cure ;  but  it  seems  probable  that  it  may  do  more  than 
some  other  remedies  toward  arresting  the  progress  of  the  disease, 
and  perhaps  prolonging  the  period  during  which  surgical  treatment 
may  be  employed  with  some  hope  or  promise  of  success. 

"  He  had  not  lost  sight  of  the  fact  that  some  cases  of  cancer  of 
the  uterus  undergo  changes  in  their  progress  that  might  erroneously 
be  attributed  to  the  remedies  used  ;  but,  after  making  due  allowance 
for  that  source  of  error,  there  still  remains  something  to  be  said  in 
favor  of  the  drug  in  question." 

I  have  myself  had  no  experience  with  aveloz,  nor  should  I  men- 
tion it  here  did  it  not  have  the  indorsement  of  so  good  an  authority 
as  Dr.  Hunter. 

Caustics  seem  to  have  a  temporary  good  effect,  but  I  think  the 
activity  they  excite  may  produce  an  extension  of  the  neoplasm  itself. 


412  DISEASES   OF   WOMEN. 

Interstitial  injections  of  solutions — zinc  chloride,  and  carbolic 
acid,  have  been  tried  with  varying  success. 

Paquelin's  thermo-cautery  or  tlie  hot  iron  (the  parts  around  being 
protected)  may  be  substituted  for  caustics,  or  they  may  be  used  to 
stop  hiiemorrbage  with,  or  aid  in  closing  over,  any  sound  surface 
after  any  operation 

Simon's  scoop,  tlie  sharp  spoon,  the  curette,  or  even  the  linger- 
nail  may  be  used  to  rapidly  and  completely  remove  soft,  villous, 
semi-putrid  masses,  for  then  the  consistency  is  such  that  other  means 
can  not  be  employed,  a  firm  hold  with  an  instrument  being  impos- 
sible. 

The  scooping  should  be  thorough,  and  performed  antiseptically. 
It  causes  greater  haemorrhage  than  any  other  operation  ;  but  bleed- 
ing may  be  checked  by  any  of  the  above-named  methods.  Yet 
if  done  rapidly  it  is  possible  that  powerful  cauterization  after  a  thor- 
ough scooping  may  completely  arrest  the  progress  of  tlie  disease. 
Sims's  operation  consists  in  scooping  out  the  epithelioma  (for  it  is 
epithelioma  that  this  method  is  especially  intended  to  remove)  with 
the  sharp  spoon  or  curette,  or  cutting  it  down  with  a  scissors  or 
knife,  and  then  scooping  every  particle  of  diseased  tissue  away. 
After  thorough  drying  of  the  parts  they  are  plugged  with  j^ledgets 
that  have  been  soaked  in  saturated  alum-water  to  which  carbolic  acid 
has  been  added  (1-40),  or  in  persulj^hate  of  iron,  two  thirds  water, 
and  squeezed  dry  after  such  soaking.  The  plugs  are  removed  in 
five  days  and  then  wadding,  soaked  in  a  chloride-of-zinc  solution, 
and  squeezed  dry,  is  packed  into  the  cavity.  This  is  very  painful. 
Five  days  later  this  plug  is  removed  ;  and  the  slough  denudes  a 
granulating  surface  which  will  heal,  Sims  claims,  within  two  weeks. 

This  method  is  best  adapted  to  cases  in  which  the  disease  is 
limited  to  the  cavity  of  the  cervix. 

A  modification  of  this  I  have  frequently  practiced  in  the  class 
of  cases  referred  to ;  I  thoroughly  and  very  rapidly  remove  all  the 
diseased  tissue  with  a  curette,  and  then  plug  the  cavity  with  cotton 
and  allow  this  plug  to  remain  twenty-four  to  forty-eight  hours. 
It  is  then  removed  and  the  surface  thoroughly  cauterized  with  Pa- 
quelin's thermo-cautery  or  the  galvano-cautery.  In  case  the  bleed- 
ing subsides  promptly  after  using  the  curette,  the  parts  are  sponged 
and  pledgets  of  cotton  saturated  in  zinc  chloride  are  applied,  and  a 
dry  tampon  of  absorbent  cotton  is  placed  in  the  vagina  to  take  up 
any  of  the  zinc  solution  that  may  be  squeezed  out  of  the  cotton  by 
contraction  of  the  parts.  This  dressing  is  removed  in  about  forty- 
eight  hours,  and  then  the  patient  is  kept  at  rest  until  the  slough 


MALIGNANT   DISEASE    OF   THE    UTERUS.  413 

separates  ;  and  if  any  suspicious-looking  tissue  remains,  it  may  be 
touched  with  the  cautery. 

Amputation  of  the  cervix  is  the  chief  means  at  our  disposal  for 
the  treatment  of  malignant  disease  of  this  portion  of  the  uterus. 

The  contraindications  are :  When  the  neighboring  glands  are 
involved ;  when  (the  vaginal  portion  of  the  cervix  being  healthy) 
the  vagina  is  invaded  ;  and  when  the  cancer  closely  approaches,  or 
lias  reached,  the  junction  of  body  and  cervix. 

The  importance  of  a  thorough  physical  examination  before  de- 
ciding to  operate  is  therefore  self-evident. 

The  Scraseur  is  seldom  used  for  amputation  of  the  cervix.  It  is 
very  painful,  and  on  the  lower  sm'face  of  the  cervix  we  may  not 
reach  the  limits  of  the  cancer,  while  above,  the  chain  may  include  a 
part  of  the  vagina. 

Galvano-cautery  demands  the  same  preliminaries  and  cares  as  re- 
moval by  the  ecraseur.  I  prefer  Sims's  position  to  the  lithotomy 
position  so  often  advised  for  this  operation, 

Thomas's  forceps  grip  the  whole  cervix  and  their  projections 
prevent  slipping  of  the  wire. 

When  the  wire  fits  the  line  of  demarkation,  the  operator  should 
make  the  current  and  tighten  the  wire  very  slowly,  gently  pulling 
on  the  forceps  as  the  wire  burns  deeper ;  by  this  means  the  tissues 
will  be  made  to  assume  a  funnel-shaped  appearance  as  they  retract. 
A  careful  examination  for  diseased  tissue  should  now  be  made,  and 
should  such  be  found  it  can  be  removed  with  the  galvano-cautery 
knife,  or  the  dome  cautery  may  be  employed  to  remove  any  suspi- 
cious tissue. 

The  Germans  do  not  regard  either  of  these  methods  as  compara- 
ble with  removal  by  means  of  the  knife.  For,  it  is  claimed,  they 
confine  the  operator  to  one  cut,  whereas  the  knife  can  follow  the 
borders  of  the  new  tissue  however  irregular  they  may  be.  But  I 
am  satisfied  that  the  loss  of  blood  and  the  uncertainty  of  manipula- 
tion from  the  haemorrhage,  render  it  far  more  likely  that  diseased 
tissue  will  be  missed  in  this  operation  than  when  the  galvano-cautery 
is  employed. 

Schroeder's  operation  for  removal  of  the  vaginal  portion  of  the 
cervix  consists  in  cutting  both  sides  of  the  cervix  so  as  to  make  two 
lips — anterior  and  posterior — and  then  excising  a  wedge-shaped  por- 
tion from  each ;  the  flaps  are  then  stitched  together  and  the  incisions 
first  made  are  last  of  all  closed  by  sutures. 

This  operation  is  only  apphcable  to  those  cases  seen  very  early  in 
the  disease. 


414:  DISEASES   OF   WOMEN.  ■ 

Scliroeder's  snpra-vagiiial  o])eration  consists  in  cutting  through 
the  vairinal  raucous  membrane  at  the  anterior  fornix,  the  cervix 
being  pulled  down  and  firmly  held,  8oj)arating  the  bladder  uj)  to 
the  utero-vesical  pouch  of  j)eritonieum,  then  carrying  the  cervix 
forward  and  cutting  the  mucous  raendjrane  of  the  posterior  fornix 
in  a  like  manner. 

Some  regard  injury  to  Douglas's  cul-de-sac  as  dangerous ;  others 
claim  that  the  pouch  can  be  cut  into  and  some  of  the  peritonfEum 
removed  with  the  tumor. 

The  next  step  is  to  cut  with  knife  or  scissors  above  the  lateral 
fornices,  taking  care  to  avoid  wounding  the  branches  of  the  uterine 
artery.  Thus,  we  see  great  care  must  be  taken  in  the  preliminary 
clearing  away  of  the  cervix. 

The  operator  now  cuts  through  the  anterior  cervical  wall  in  the 
healthy  tissue  above  the  tumor,  opens  the  cervical  cavity,  and  stitches 
the  anterior  vaginal  wall  to  the  anterior  wall  of  the  cervix.  The 
cei^vix  thus  being  held  in  place  it  is  amputated  when  the  knife 
passes  through  the  posterior  wall  which  is  to  be  stitched  to  the  pos- 
terior vaginal  wall. 

The  lateral  wounds  are  closed  with  deep  sutures  which  are  meant 
to  diminish  the  opening  into  the  pelvic  connective  tissue,  and  to  ar- 
rest haemorrhage. 

Should  the  vagina  be  affected  it  is  to  be  severed  at  the  distance 
of  half  an  inch  from  the  carcinoma. 

Baker,  of  Boston,  advocates  a  "  high  amputation,"  which  is 
meant  for  a  substitute  for  the  entire  removal  of  the  uterus  by 
Freund's  or  Schroeder's  methods.  It  is  claimed  for  it  that  more  of 
the  uterus  can  be  removed  than  by  any  other  amputation ;  that  it  is 
far  more  practical  for  the  general  practitioner  than  vaginal  hyste- 
rectomy ;  that  more  recoveries  follow  and  fewer  recurrences  of  the 
neoplasm  have  been  observed.  The  patient  is  placed  in  Sims's  po- 
sition, the  cervix  is  pulled  down  to  the  outlet,  and  the  su]u-a-vaginal 
cervix  is  separated  from  the  bladder  in  front,  and  the  peritonjpum 
behind,  up  to  the  internal  os.  These  two  incisions  are  connected 
by  lateral  cuts;  and  then  a  funnel-shaped  portion  of  the  body  is 
removed  by  the  uterotome.  As  the  incision  begins  much  higher 
than  in  Sims's  operation,  we  can  remove  not  only  the  entire  cervix, 
but  almost  half  the  body  of  the  uterus.  Actual  cautery— red  heat 
— is  applied  to  the  whole  denuded  surface ;  and  no  tampon  is  em- 
ployed to  control  the  haemorrhage. 

One  of  the  most  daring  advances  in  gynecology  is  the  introduc- 
tion of  an  operation  invented  and  performed  by  W.  A.  Freund,  hence 


MALIGNANT  DISEASE   OF  THE   UTERUS.  415 

called  "  Freimd's  operation";  it  is  the  extirpation  of  the  entire 
uterus. 

Excision  of  tlic  uterus  is  appropriate  when  cervical  malignant 
growths  are  extending  or  threaten  to  extend  upward,  or  when  there 
is  actual  disease  of  the  body. 

Freund's  operation — by  abdominal  incision — is  as  follows  :  The 
incision  is  made  from  the  umbilicus  to  the  symphysis  pubis,  and  the 
intestines  are  held  up  toward  the  diaphragm  by  warm,  fine-linen 
cloths  (soaked  in  some  antiseptic  solution)  from  the  beginning  to  the 
end  of  the  operation.  The  recti  abdominales  are  separated  so  that 
the  pelvis  can  be  thoroughly  inspected.  The  parietal  peritonaeum 
is  stitched  to  the  abdominal  coverings,  or  a  thread  is  passed  through 
the  fundus  uteri,  and  another  through  the  peritonaeum  of  the  anterior 
part  of  the  pelvis,  both  threads  being  held  by  assistants. 

The  uterus  is  grasped  by  forceps — Freund's  or  any  good  instru- 
ment may  be  used — drawn  upward,  and  three  ligatures  are  then 
applied  to  each  broad  ligament.  These  ligatures  are  called  the  upper, 
middle,  and  lower,  the  two  np]3er  passing  through  the  broad  liga- 
ment, while  the  lowest  includes  the  parametrium  laterally,  and  with 
it  the  uterine  arteries  and  the  vaginal  vault. 

In  detail,  the  first  suture — double  silk — passes  through  the  ova- 
rian ligament  from  behind,  and  through  the  broad  ligament  just 
below  the  free  margin,  in  order  that  the  ovarian  artery  may  be  in- 
cluded when  this  loop  is  tied. 

The  second  ligature  passes  through  the  ovarian  ligament  along- 
side of  the  first,  and  then  through  the  round  ligament,  so  that  a 
second  loop  is  formed,  which,  tied  anteriorly,  controls  the  pampini- 
form plexus. 

The  third  suture  is  best  carried  by  a  special  needle  designed  by 
Freund,  which  is  guarded  by  a  trocar.  So  sheathed,  it  follows  the 
finger  of  the  operator  in  the  vagina,  pierces  the  vaginal  wall  twice 
— first  through  the  antero-lateral  portion  of  the  vaginal  roof  into 
the  vagina,  and  (secondly)  back  through  the  postero-lateral  part  of 
the  vaginal  cul-de-sac — behind  the  base  of  the  lateial  ligament,  into 
the  pouch  of  Douglas. 

The  lateral  fornix  is  pierced  twice  with  this  needle  by  grasping 
the  free  end  of  the  double  thread  as  soon  as  the  first  penetration  is 
made,  and  holding  it  while  the  needle,  pulled  backward,  runs  on  the 
thread,  and  thus  can  carry  the  suture  a  second  time  through  the  lat- 
eral fornix.  The  thread  is  cut  beyond  the  eye  of  the  needle  after 
this  last  manoeuvre,  and  the  end  cut  is  carried  through  the  round 
ligament  completing  this  ligature,  and  controlling  the  uterine  ai'tery. 


41C  DISEASES  OF  WOMEN. 

A  catheter  in  the  bladder  serves  partly  as  a  guide  to  the  next 
step,  which  commences  the  excision  of  the  organ.  The  utero-vesical 
pouch  is  cut  tlirough,  and  the  peritonaeum  resting  on  the  bladder  is 
sewed  to  the  subjacent  tissue. 

The  peritonaeum  of  Douglas's  cut-de-sac  is  cut  and  treated  in  a 
similar  manner.  Freund  separates  the  cellular  tissue  with  the  finger 
in  preference  to  an  instrument.  Finally,  each  broad  ligament  is  cut 
internal  to  the  three  ligatures,  and  the  uterus  is  removed.  The  ends 
of  the  ligatures  are  drawn  into  the  vagina,  the  intestines  are  replaced, 
and  all  subsequent  treatment  is  as  after  ovariotomy. 

Only  a  little  over  twenty-five  per  cent  of  recoveries  after  this 
operation  have  been  recorded.  Haemorrhage  may  be  particularly 
severe,  and  with  shock  and  possible  inclusion  of  the  ureter,  it  is  one 
of  the  dangerous  sequeke  of  ablation  of  the  uterus  by  Freund's 
method. 

Schroeder  has  modified  and,  I  think,  improved  Freund's  opera- 
tion, which,  according  to  the  former,  is  thus  performed.  "While  the 
uterus  is  finnly  held  down  in  the  vagina  as  close  to  the  vulva  as 
possible,  the  first  cut  is  made  through  the  utero-vesical  pouch,  but 
the  peritonaeum  is  not  injured. 

The  next  step  is  to  free  the  cervix  behind,  and  open  into  the 
pouch  of  Douglas.  Two  fingers  are  then  passed  into  the  last  cut, 
and  brought  forward  over  the  fundus  down  into  the  vesico-uterine 
pouch,  and,  while  they  are  in  this  position,  the  peritonaeum  is  di- 
vided. The  fingers,  thus  hooked  over  the  fundus,  retroflex  it,  unless 
the  utenis  is  very  unyielding  or  hard,  or  the  vagina  is  very  small, 
and  pull  it  out  through  the  posterior  wound.  Sometimes  forceps 
are  necessary  to  do  this.  Each  broad  ligament  is  ligated  in  two 
places,  and  a  third  ligature  encircles  the  whole. 

The  utenis  is  now  cut  free  from  everything,  and  the  two  pedicles 
are  brought  into  the  vaginal  wound,  each  being  sutured  to  both  the 
anterior  and  posterior  fornix. 

A  di-ainage-tube  is  inserted  into  the  cavity  of  the  pentonjeum 
between  the  stumps. 

The  vagina  is  packed  with  antiseptic  dressing.  Finally,  the 
sutures  are  removed  in  from  ten  to  twelve  days. 

Schroeder  claims  the  same  percentage  of  recoveries  (seventy-five 
per  cent)  as  Freund's  statistics  exhibit  for  deaths. 

From  the  frightful  mortality  of  Freund's  abdominal  method,  it 
has  come  to  be  almost  abandoned,  and  vaginal  hysterectomy — just 
described  in  detail — has  taken  its  place. 

Statistics  regai'ding  vaginal  hysterectomy  are  not  reliable,  nor  as 


MALIGNANT  DISEASE   OF  THE   UTERUS.  417 

yet  very  useful,  first,  because  unsuccessful  cases  arc  seldom  reported, 
and  secondly,  because  only  a  small  number  of  cases  at  best  have  been 
publislied. 

Scbroeder  says  if  one  person  out  of  twenty  be  cured,  this  ought 
to  be  considered  a  good  result.  He  also  admits  that  recurrence  is 
frequent  after  vaginal  extirpation. 

If  ablation  of  the  entire  organ  by  Schroeder's  method  should  be 
performed  only  when  cancer  affects  the  body,  or  in  those  cases 
where  it  is  limited  to  the  cervical  mucosa,  and,  in  either  case,  when 
the  vagina  is  capacious  enough  not  to  oppose  difficulties  to  the 
operation,  then  I  think  it  will  be  a  most  difficult  matter  to  decide 
when  to  perform  vaginal  hysterectomy,  for  it  is  doubtful  if  the 
touch  can  determine  infiltration  of  the  lymphatics.  At  the  present 
day  there  are  no  known  ante-mortem  means  of  determining  with 
certainty  whether  the  uterus  is  or  is  not  the  sole  locus  of  malignant 
disease.  Again,  when  cancer  is  limited  to  the  cervical  mucosa,  its 
detection  is  very  rare. 

It  would  seem  that  vaginal  hysterectomy,  according  to  Schroed- 
er's own  statements,  is  destined  to  become  a  rare  operation. 

CANCER  OF  THE  BODY  OF  THE  UTERUS. 

This  condition,  though  rare  as  compared  with  carcinoma  of  the 
cervix,  is  by  no  means  a  phenomenon. 

Pathology. — In  corporeal  epithelioma  the  epithelium  of  the 
uterine  glands  undergoes  hypertrophy,  and  there  is  formed  a  fungat- 
ing  polypoidal  mass,  which  propagates  itself  over  all  the  organ,  or 
projects  into  its  cavity,  perhaps  into  the  cavity  of  the  cervix. 

The  cancerous  mass  always  ulcerates  and  leaves  wide  cavities  in 
the  hardened  uterine  wall.     The  organ  is  enlarged. 

Scirrhus  or  encephaloid  may,  in  rare  cases,  be  found  in  the  body 
of  the  womb,  although  the  best  authorities  state  that  there  is  scarcely 
an  unquestionable  case  of  corporeal  encephaloid,  and  that  scirrhus 
has  never  been  met  with. 

These  varieties  form  beneath  the  mucosa  in  the  substance  of  the 
uterine  tissue,  and  extend  outward,  causing  peritonitis  and  agglutina- 
tion with  neighboring  organs  and  parts.  AVhen  they  extend  inward 
they  are  certain  to  ulcerate. 

Either  form  of  cancer,  when  accompanying  fibroids,  does  not 
seem  to  modify  the  latter's  characteristics.     One  case  is  recorded  of 
caulitiower  excrescence  of  the  fundus  ;  this  projected  out  through 
the  cervix  down  into  the  vagina. 
28 


418  DISEASES   OF   WOMEN. 

The  microscopical  appearances  in  no  wise  differ  from  similar 
neoplasms  in  the  cervix  (</.  y.). 

/Symptams. — The  pi-ominent  symptoms  of  cancer  of  the  cervix 
(q.  i\)  are  also  met  with  in  cancer  of  the  body,  l)ut  not  to  the  same 
degree  nor  appearing  in  the  same  oi'der. 

Pain  occurs  early,  and  is  severe  and  paroxysmal,  sometimes  re- 
maining at  its  pitch  for  two  hours.  Intense  menorrhagia  is  soon 
accompanied  by  a  discharge  which  is  profuse,  watery,  and  fetid.  In 
some  instances  there  will  be  no  discharge  whatever  throughout  the 
disease.  The  vital  forces  are  early  greatly  depreciated,  and  marked 
constitutional  disturbance  is  a  prominent  early  symptom  of  cancer 
of  the  corpus. 

Physical  Signs. — Inspection  gives  negative  results.  On  palpa- 
tion (bimanual)  the  body  is  felt  to  be  larger  and  harder  than  normal. 
The  cervix  is  usually  dilated,  but  in  a  few  instances  has  been  felt 
to  be  normal.  Adhesions  may  firmly  hold  the  uterus  in  a  fixed  posi- 
tion, or  just  as  often  it  is  freely  movable. 

On  dilating  the  os  with  sponge-tent  or  finger,  uterine  tenesmus 
results,  and,  if  we  can  enter  the  organ,  the  finger  readily  recognizes 
the  condition  of  affairs  within  the  corporeal  cavity. 

The  probe  induces  profuse  haemorrhage  in  nearly  all  cases,  and 
by  its  use  we  learn  the  degree  of  dilatation  of  the  cavity  of  the 
womb. 

The  curette  is  used  to  withdraw  some  of  the  growth  for  micro- 
scropical  examination. 

Diagnosis. — Cancer  of  the  body  and  cancer  of  the  cervix  may 
be  confounded  with  each  other.  The  points  that  enable  us  to  dis- 
tinguish them  are  these :  Cancer  of  the  body  is  very  rare ;  that  of 
the  cervix  comparatively  common ;  pain  is  very  early  and  very  severe 
in  cancer  of  the  body  ;  it  is  rare  or  absent  in  cervical  cancer.  Men- 
struation is  deranged  from  the  very  onset  in  cancer  of  the  body ; 
this  is  a  late  symptom  when  the  cervix  is  attacked. 

Marked  constitutional  disturbance  and  peritonitis — which  is  often 
fatal — occur  early  and  more  frequently  in  cases  where  the  body  is 
the  seat  of  malignant  growth  than  when  the  cervix  is  involved. 
There  is  little  or  no  tenesmus  on  bimanual  examination  in  cancer 
of  the  cervix,  while  this  is  marked  in  cancer  of  the  body.  The 
probe  discovers  an  enlarged  corpus  in  the  latter  case,  while  in  cancer 
of  the  cervix  the  corpus  is  normal  in  size.  The  adjoining  structures 
are  implicated  far  more  frequently,  and  also  earlier  in  the  disease, 
in  cancer  of  the  body  than  in  cancer  of  the  cervix. 

Prognosis. — The  same  rules  hold  good  here  as  in  cancer  of  the 


MALIGNANT  DISEASE   OF  THE  UTERUS.  419 

cervix.  The  outlook  for  recovery  is  far  less  favorable,  not  only  from 
the  situation  of  the  growth  and  the  greater  likelihood  of  adjacent 
tissues  being  involved,  but  also  from  the  fact  tliat,  as  total  extirpa- 
tion is  the  sole  means  of  treatment,  the  probability  of  life  after  this 
operation  is  much  less  than  after  amputation,  cautery,  or  scooping. 

Etiology. — The  body  of  the  uterus  is  attacked  with  cancer  very 
much  more  frequently  in  nulliparns  than  in  multiparse,  which  is  in 
striking  contrast  with  the  prevalence  of  cancer  of  the  cervix.  The 
average  age  of  patients  suffering  corporeal  carcinoma  is  ten  years 
o-reatcr  than  that  of  women  afflicted  with  cancer  of  the  cervix.  In 
every  other  respect  the  causation  is  the  same  as  in  cervical  cancer. 

Treatment. — Extirpation  is  the  sole  means  of  effecting  a  cure  in 
cancer  of  the  body,  and  hysterectomy  seems  to  be  followed  by  far 
better  results  in  these  cases  than  when  performed  for  cancer  of  the 
cervix.  This  may  be  accounted  for  on  the  ground  that  in  the  neigh- 
borhood of  the  cervix  there  is  far  greater  liabihty  to  extension  of 
the  disease  and  infiltration  downward  and  laterally. 


SARCOMA    OF    THE    UTERUS. 

Fibroplastic  tumors  or  "  recurrent  fibroids,"  are  neoplasms  of  the 
embryonic  tissue  type  whose  seat  is  usually  in  the  body  of  the 
utenis. 

Pathology. — The  connective  tissue  is  the  origin  of  uterine  sarco- 
ma; and  immediately  beneath  the  epithelium  this  tissue  forms 
nodules  or  ridges  which  bulge  out  the  softened  and  somewhat  dis- 
integrated mucosa  into  the  uterine  cavity. 

Since  the  projections  are  often  polypoidal,  pedunculated,  soft, 
and  medullary  in  consistence,  rapid  in  their  groAvth,  and  vascular,  it 
is  easy  to  see  how  they  can  be  mistaken  for  carcinoma.  Indeed, 
Klebs  has  found  a  profuse  epithelial  growth  upon  sarcomatous  nod- 
ules of  the  uterus  and  then  the  growths  seem  to  have  joined. 

The  uterus  may  be  greatly  distended  by  the  fungus-like  growth. 

When  the  mucous  membrane  is  wholly  disintegrated,  the  uterus 
may  be  perforated,  and  in  rare  instances  the  sarcoma  may  prolifer- 
ate out  through  the  abdomen. 

In  other  cases  the  growth  is  deeper,  less  diffuse,  and  more  nodu- 
lar. It  begins  anywhere  in  the  uterine  tissue  between  the  submu- 
cous layer  and  the  peritoneal  investment  and  forms  a  hard,  roundish 
mass  like  a  fibroid.  This  may  assume  a  fungoid  or  polypoid  form 
and  hang  down  in  the  uterine  cavity  ;  as  in  cancer,  so  here,  the  soft 
may  be  a  later  stage  of  the  hard  sarcoma. 


420  DISEASES  OF  WOMEN.  ' 

Possibly  a  degenerating  tibroid  of  the  uterus  may  be  associated 
with  a  sarcoma ;  or,  as  it  tlien  would  be  called  a  Hbro-sarcoma. 

Microscopically,  the  round  or  spindle-shaped  cells  are  seen 
crowding  the  section,  the  former,  as  a  rule,  being  the  ordinary  vari- 
ety found  in  the  uterus.  The  tumor  is  permeated  with  a  nieshwork 
of  wide  but  thin-walled  blood-vessels  characteristic  of  this  neoplasm. 

When  the  round  cells  are  very  large  there  is  giant-celled  sar- 
coma, or  myeloid  sarcoma. 

As  to  the  effects,  the  vagina,  peritonaeum,  Fallopian  tubes,  and 
ovaries  may  be  invaded  by  sarcomatous  masses. 

The  uterus  is  often  inverted,  either  from  an  easily  dilated  cervix 
or  from  weakening  or  palsy  of  the  uterine  muscle. 

Symptoms. — The  classical  symptoms  of  malignant  disease — pain, 
haemorrhage,  and  discharge,  are  met  in  cases  of  sarcoma  uteri. 

Pain,  however,  occurs  late,  if  at  all,  and  seems  to  have  often 
been  confounded  with  uterine  tenesmus  which  is  a  common  s^nup- 
tom.  At  times  there  may  be  severe  pain  from  pressure  on  the  rec- 
tum and  bladder. 

Menorrhagia  is  an  early  symptom  ;  or  if  the  disease  is  in  those 
who  have  passed  the  menopause,  menstruation  seems  to  have  re- 
turned. Later,  there  is  a  discharge  resembling  the  rice-water  stools 
of  cholera  which  is  only  faintly  suggestive  of  the  cancerous  odor. 
But  as  the  neoplasm  ulcerates,  the  discharge  is  as  fetid  as  that  of 
carcinoma,  and  in  it  are  pale-gray  shreds  which,  upon  microscopical 
examination,  at  once  reveal  the  true  nature  of  the  growth. 

A  cachexia  is  very  slowly  and  gradually  developed,  yet  finally  it 
is  as  marked  as  in  cancer. 

Physical  Signs. — Palpation  reveals  a  soft,  friable,  pedunculated 
tumor  which  may  be  felt  to  spring  from  the  body  of  the  uterus. 
The  OS,  through  which  this  tumor  is  forced  is  dilated,  softened,  and 
iiTegular.  The  finger  or  the  sponge-tent  may  be  used  to  dilate  the 
cervical  canal  when  the  mass  has  not  yet  made  its  way  down  to  the 
OS  internum. 

Bimanual  palpation  shows  the  uterus  to  be  large,  sometimes 
reaching  half-way  to  the  umbilicus,  and  oftentimes  as  irregular  as 
when  the  seat  of  fibromata. 

The  sound  shows  the  extent  of  the  enlargements ;  its  use  causes 
intense  menorrhagia. 

The  curette  is  useful  to  obtain  scrapings  for  microscopic  exami- 
nation. 

Diagnosis. — Sarcoma  may  be  mistaken  for  carcinoma ;  but  in 
the  latter  disease  pain  is  a  far  more  frequent,  early,  and  severe  sjTup- 


MALIGNANT   DISEASE   OF   THE   UTERUS.  421 

torn  ;  the  discharge  is  fetid  almost  from  the  very  onset ;  the  cervix 
is  most  difficult  to  dilate  with  a  sponge-tent ;  the  constitutional 
symptoms  are  more  severe  ;  and  the  duration  of  the  disease  is  rarely 
over  a  year.  These  symptoms  are  in  contrast  with  what  occurs  in 
sarcoma. 

Finally,  a  microscopic  examination  of  some  of  the  scrapings  will 
always  be  necessary  before  determining  the  diagnosis. 

Prognosis. — Although  a  patient  with  sarcoma  of  the  uterus 
lives  on  the  average  three  or  four  years  after  the  tumor  is  fairly  de- 
veloped, yet  the  outlook  for  ultimate  recovery  is  most  grave,  all  cases 
slowly  but  surely  tending  toward  a  fatal  issue. 

Sarcoma  tends  to  reappear  after  most  careful  removal,  although 
the  time  elapsing  between  removal  and  recurrencs  is  much  longer 
than  in  the  case  of  carcinoma. 

The  prognosis  will  greatly  depend  upon  an  examination  of  the 
scrapings — when  these  show  scanty  stroma  with  an  abundance  of 
cell  elements  the  course  will  probably  be  as  rapid  as  that  of  enceph- 
aloid  cancer,  but  when  the  cells  are  few  and  the  iibrous  tissue  is 
abundant  life  may  be  prolonged  for  six  or  eight  years. 

Among  the  complications  are  septicaemia,  anaemia,  peritonitis, 
and  sarcomatous  nodules  in  adjacent  organs. 

Etiology. — Age  is  the  chief  predisposing  cause ;  half  of  all  the 
cases  occur  between  the  ages  of  forty  and  hfty,  and  before  thirty  or 
after  sixty,  sarcoma  is  extremely  rare. 

In  cancer  I  referred  to  the  occurrence  of  the  disease  in  those 
who  had  borne  many  children ;  but  sarcoma  seems  to  develop  in 
sterile  wombs  in  nearly  fifty  per  cent  of  the  recorded  cases. 

It  is  a  mooted  question  whether  traumatism  and  uterine  inflam- 
mation have  any  influence  in  the  causation  of  sarcomata. 

Treatment. — When  pedunculated  tumors  project  into,  or  out 
through  the  cervix,  the  sharp  spoon  or  the  galvano-cautery  or  even 
the  finger-nail  may  be  used  to  remove  them.  Then  carbolic  or 
nitric  acid  may  be  applied  to  the  base  of  the  tumor. 

When  the  growth  is  not  sessile  but  apparently  superficial, 
thorough  curetting  and  the  application  of  nitric  or  carbohc  acid  are 
advocated. 

Deep  sarcomata  can  only  be  treated  by  extirpation  of  the  uterus. 


CHAPTER  XXIII. 

THE   ]MENOPAUSE. 

The  menstrual  function  is  jjermanently  suspended  about  the  age 
of  forty-five  years.  This  cliauge  in  the  habit,  which  is  so  important 
in  middle  life,  is  known  by  several  names,  such  as  the  change  of 
life,  the  climacteria,  critical  time,  turn  of  life,  and  the  menopause.  I 
prefer  the  latter  term  as  it  l)est  expresses  that  which  takes  place. 

Although  forty-five  is  the  average  age  at  which  this  change  takes 
place,  there  is  very  great  variation  in  regard  to  time.  The  cessa- 
tion of  menstruation  has  occurred  as  early  as  twenty-one,  and  as 
late  as  sixty-one  years  of  age,  but  such  cases  are  rare  exceptions,  and 
may  be  looked  upon  as  curiosities  and  altogether  abnormal. 

The  limits  of  variation  which  appear  to  be  in  keeping  with 
health,  and  hence  may  be  considered  normal,  are  at  forty  and  fifty 
years.  The  change  comes  in  the  vast  majority  between  forty  and  fifty 
years,  and  those  who  come  within  that  space  of  time  may  be  consid- 
ered as  normal  unless  there  is  some  morbid  state  accompanying  the 
change,  which  may  influence  it. 

"While  marked  variation  in  time  is  not  incompatible  with  health 
it  should  be  noticed  that  when  there  is  a  marked  deviation  from  the 
average  time,  forty-five  years,  there  is  always  a  ])ossibility  of  some 
morbid  state  being  present  which  is  the  cause  of  the  deviation.  This 
point  should  be  investigated  in  all  cases. 

Natural  History  of  the  Menopause. — The  changes  which  occur  in 
the  organs  of  generation  at  the  menopause  constitute  a  complete  in- 
volution, and  are  in  marked  contrast  to  those  which  take  place  in 
evolution  of  puberty. 

The  two  processes,  the  one  the  beginning,  the  other  the  end  of 
functional  life,  are  completely  opposite  in  character,  and  yet,  in 
some  of  their  manifestations  and  eilects  upon  the  general  system, 
they  have  many  features  in  common. 

The  menopause  in  the  limited  sense  of  the  term  indicates  the 


THE  MENOPAUSE.  423 

cessation  of  the  menstrual  function,  but  in  the  whole  process  of  in- 
volution which  constitutes  the  "change  of  life,"  there  are  two 
sta<-es  The  first  extends  from  the  beginning  of  involution  and  the 
decline  of  functional  activity,  the  precessation  period;  and  the  sec- 
ond which  extends  from  the  time  that  menstruation  ends  to  the 
completion  of  involution  and  the  adaptation  of  the  general  system 
to  the  new  order  of  things,  the  post-cessation  period. 

The  changes  of  structure  which  take  place  at  the  menopause, 
are  atrophic  in  character.     The  ovaries  gradually  diminish  m  size 
and  the  Graafian  follicles  disappear,  at  least  it  is  difecult  to  lind 
them      When  the  involution  of  the  ovaries  is  complete,  there  is 
little  left  of  them  in  some  cases,  except  a  small  mass  of  fibrous  and 
cellular  tissue,  to  indicate  where  they  have  been.     Similar  changes 
tike  place  in  the  Fallopian  tubes,  uterus,  and  vagina,     ihe  tubes 
contract  and  become  obliterated,  the  uterus  is  reduced  to  the  size 
and  something  of  the  shape  of  the  infantile  uterus,  and  the  vagina 
becomes  shorter  and  narrower. 

The  chano-e  in  the  blood-vessels  is  also  quite  marked,  ihe  ves- 
sels contract  until  the  evidence  of  vascularity  of  the  pelvic  organs 
which  exists  in  middle  life,  is  almost  obliterated. 

This  involution  in  structure  takes  place  slowly,  as  a  rule,  but 
when  completed  the  sexual  organs  are  reduced  by  atrophy  to  the 
rudimentary  state,  and  are  quite  anaemic.  -n     -,.    . 

During  the  precessation  stage,  while  the  flow  is  gradually  dimm- 
ishino"  or  coming  at  irregular  intervals,  and  also,  for  some  time, 
during  the  post-cessation  time,  there  are  some  disorders  of  the  nutri- 
tive and  nervous  system  which  occur  in  the  most  healthy  women, 
but  they  are  of  such  a  trivial  nature  that  they  are  borne  without 
attention  being  called  to  them.  They  expect  some  discomfort  at 
that  time  of  life,  and  the  system  soon  adapting  itself  to  the  new  or- 
der of  things,  complete  harmony  of  action  is  estabbshed,  and  future 
good  health  follows. 

Of  course,  the  rearrangement  of  the  system  takes  more  time 
with  some  than  with  others,  and  the  degree  of  discomfort  attending 
the  change  varies  greatly,  so  that  the  line  of  demarkation  between 
the  normal  and  morbid  is  narrow  and  ill-defined. 

In  the  majority  of  healthy  women  there  are  usually  some  dis- 
turbances of  the  nervous  system,  and  the  organs  of  general  nu- 

trition. 

The  chief  symptoms  presented  by  the  nervous  system  are  occa- 
sional headaches,  irregular  flushing  of  the  face,  sudden  changes  in 
the  temperature  of  the  hands  and  feet,  general  irritability  ol  the 


424  DISEASES   OF   WOMEN. 

nervous  system,  and  torpor  or  sluggishness  of  the  brain.  These,  with 
a  great  variety  of  other  symptoms,  are  not  sufficient  to  greatly  dis- 
tress the  patient  and  yet  are  quite  enough  to  be  noticed. 

There  arc  often  some  gastrointestinal  disturbance  and  impaired 
ultimate  nutrition,  so  that  patients  suffering  in  this  way  com]>lain 
of  indigestion.  Such  symptoms  not  only  appear  during  the  decline 
of  the  menstrual  function  but  continue  during  the  post-cessation 
period. 

Those  who  have  observed  most  carefully  the  resemblance  in  cer- 
tain ways  between  puberty  and  the  nienopause,  claim  that  those 
who  suffer  at  puberty  are  liable  to  do  so  at  the  menopause.  This  is 
often  the  case,  no  doubt,  as  those  who  begin  wrong  are  likely  to  end 
in  a  similar  manner. 

Provision  is  made  at  puberty  for  the  menstrual  function,  as  has 
already  been  pointed  out,  and  it  may  be  briefly  stated  that  a  like 
provision  is  made  in  women  in  health  for  giving  up  that  function. 

During  involution,  and  especially  after  the  cessation  of  menstru- 
ation, the  secretion  from  the  skin  is  increased  ;  the  urine  salts  are 
more  abundant ;  there  is  a  freer  elimination  of  carbonic  acid  from 
the  lungs.  The  skin  acts  more  freely,  and  there  is  often  a  free  ac- 
tion of  all  the  mucous  membranes.  This  shows  that  the  process 
of  elimination  is  more  active  in  every  way  and  compensates  for 
menstruation.  Indeed,  the  increased  activity  in  elimination,  in  some 
cases,  appears  to  be  out  of  proportion  to  that  which  is  necessary  to 
compensate  for  menstruation.  Should  these  compensating  changes 
in  the  nutritive  system  fail,  the  subject  is  sure  to  suffer  more  or  less. 

Kegarding  the  management  of  patients  at  the  menopause,  the 
reader  should  recall  the  facts  stated  when  discussing  the  care  of  girls 
at  puberty.  The  same  rules  of  hygiene  which  should  be  observed 
when  the  menstrual  function  is  being  established,  are  equally  effect- 
ive when  that  function  is  being  given  up.  Bearing  in  mind  that  the 
sexual  organs  are  preserved  in  health  largely  through  the  agency  of 
the  nutritive  and  nervous  system,  every  effort  should  be  made  to  pre- 
serve good  general  health  at  the  menopause.  All  causes  which  act 
unfavorably  upon  the  nervous  system  should  be  guarded  against. 

Those  who  live  generously  and  exercise  little,  should  take  less 
food  and  do  more  work,  while  those  who  are  overtaxed  and  poorly 
fed,  should  have  rest  and  a  better  diet. 

Any  disease  or  derangement  of  the  functions  of  the  sexual  or- 
gans which  may  exist  when  the  patient  is  drawing  near  to  the  time 
for  the  cessation  of  the  menses,  should  be  attended  to.  Much  harm 
has  arisen  by  physicians  advising  patients  who  are  suffering  from 


THE  MENOPAUSE.  425 

symptoms  referring  to  the  pelvic  organs  to  have  patience,  and  they 
will  be  all  right  after  the  change  comes. 

The  diseases  and  disorders  relating  to  the  "  change  of  life  "  may 
be  classified  as  follows :  .  .  ,. 

1.  Premature  menopause,  caused  first,  by  certain  conditions  of 
the  sexual  organs,  and,  second,  by  diseases  of  the  general  system. 

2.  Prolonged  menstruation,  caused  hrst,  by  local  diseases ;  sec- 
ondly, by  constitutional  affections. 

3.  Diseases  and  derangements  of  the  nervous  system,  due  to  the 

menopause. 

4.  Derangements  of  the  nutritive  system,  due  to  the  menopause. 

5.  Diseases  of  the  sexual  organs  due  to  the  menopause. 
Typical  cases  of  each  of  the  above-named  classes  are  frequently 

met  with,  but  more  often  the  cases  are  compHcated.  Deranged 
digestion  and  nervous  troubles  often  go  together.  Some  local  affec- 
tion and  a  general  distm'bance  are  combined,  and  in  some  of  the 
worst  cases,  the  whole  organization  is  upset. 

There  is  also  a  great  variety  in  the  character  of  the  diseases  and 
derangements  grouped  under  each  head.  In  the  disorders  of  nutri- 
tion, there  are  two  leading  forms  of  trouble :  In  the  one,  the  appetite, 
digestion,  and  assimilation  are  all  defective ;  while,  in  the  other,  dis- 
inteo-ration  and  elimination  are  most  at  fault. 

A  similar  but  far  greater  variety  of  affections  is  presented  by  the 
nervous  system.  An  almost  endless  number  of  differing  symptoms 
is  encountered  here,  which  tends  to  confusion;  still,  there  are  two 
principal  divisions  which  may  form  the  basis  of  a  classification,  viz., 
those  which  manifest  morbid  excitation  of  the  nervous  system  and 
those  which  show  a  depression. 

There  is,  of  course,  a  marked  distinction  between  those  who 
suffer  from  derangement  of  the  organic  nervous  system  and  those 
in  whom  the  cerebro-spinal  system  is  affected. 

ILLUSTRATIVE    CASES. 

A  Case  iUustrating  the  Normal  Menopause.— A  lady  who  had  a 
very  good  constitution,  and,  with  the  exception  of  having  had  some 
acute  diseases  in  early  life,  had  enjoyed  uniform  good  health.  She 
had  borne  five  children,  and  after  the  birth  of  the  last  one  she  men- 
struated regularly  and  perfectly.  When  she  was  forty-six  years 
old,  the  menstrual  flow  began  to  diminish  in  quantity  and  duration, 
varying  a  little  in  this  respect  from  time  to  time.  Iij^six  months 
from  the  time  that  the  change  began,  the  duration  of  the  flow  was 
reduced  from  five  days  to  two.     She  then  missed  two  periods,  and 


426  DISEASES  OF  WOMEN. 

tbeii  the  flow  returned,  and  lasted  three  days,  and  was  a  little  freer. 
Then  she  went  for  four  months,  when  there  was  a  slight  show  for 
part  of  a  day,  and  that  was  the  end. 

During  the  time  when  the  gradual  diminution  of  the  flow  was 
taking  place,  she  became  somewhat  languid  and  indisposed  to  her 
usual  mental  and  physical  activity,  llcr  appetite  was  not  quite  as 
good  as  formerly.  While  languid  when  undisturbed,  she  was  ea.'^ily 
roused  by  any  excitement.  Her  face  would  become  flushed,  her 
hands  and  feet  clammy,  and  she  was  nervous  and  irritable.  When 
these  feelings  passed  away,  she  felt  annoyed  to  think  that  she  could 
not  control  herself  as  in  times  past,  and  would  become  a  little  de- 
spondent. All  these  symptoms  were  more  pronounced  at  the  men- 
strual periods.  When  sufliering  most  she  felt  that  if  she  couhl  have 
a  free  menstrual  flow  it  would  relieve  her.  These  feelings  continued 
to  annoy  her  until  the  flow  ceased  entirely,  and  for  about  nine  months 
afterward,  but  they  diminished  in  severity,  and  Anally  left  her  alto- 
gether. 

After  the  cessation  of  the  flow,  she  gained  considerable  flesh,  and 
her  former  mental  and  physical  activity  returned,  and  her  health  has 
been  excellent  ever  since. 

When  the  diminution  in  the  flow  began,  and  her  peculiar  symp- 
toms came  on,  she  consulted  me  about  her  condition.  When  told 
that  all  could  be  attributed  to  the  change  of  life,  she  pleasantly  ac- 
cepted the  situation,  and  made  no  change  in  her  mode  of  life,  nor 
did  she  take  any  medicine.  This  enabled  me  to  obtain  the  liistory 
of  the  case  unmodified  by  treatment. 

Premature  Menopause  caused  by  Deranged  Innervation. — The  pa- 
tient was  one  having  a  good  organization,  but  a  very  marked  nervous 
temperament.  She  had  three  children,  the  youngest  of  whom  was 
five  years  of  age  when  I  first  saw  her.  She  was  then  thirty-six  years 
old.  Three  years  before  our  first  consultation  she  had  many  exciting 
cares  thrust  upon  her,  which  affected  her  nervous  system  very  injuri- 
ously. Though  possessed  of  means  sufficient  to  secure  every  luxury 
of  life,  her  cares  depressed  her  greatly,  and  exhausted  her  nervous 
system.  Her  nutrition  was  impaired  to  some  extent,  but  still  she 
had  the  appearance  of  one  in  fair  health,  although  she  was  restless, 
sleepless,  had  headache  very  often,  and  snft'ered  fi-om  wandenng 
neuralgic  pains. 

Her  sufferings  in  this  way  had  continued  for  about  one  year, 
during  whicji  time  the  menstrual  flow  was  at  times  scanty  and  less 
in  duration  than  normal.  Then  the  menses  stopped  altogether  for 
six  months,  then  returned  for  several  months,  though  scantily,  then 


THE  MENOPAUSE.  42Y 

ceased  for  two  months,  returned  once,  and  then  again  in  four  months, 
and  then  stopped  entirely. 

Five  months  after  the  hist  menstruation  was  the  time  that  I  first 
saw  her.  She  consulted  me  because  she  fancied  that  if  her  menses 
would  return  her  health  would  improve.  To  describe  her  symptoms 
would  be  tedious  and  unprofitable  ;  suffice  it  to  say  that  she  presented 
typical  neurasthenia.  There  was  no  organic  disease  noticeable  out- 
side of  the  nervous  system.  Being  fully  satisfied  that  if  the  men- 
strual function  could  ever  be  restored,  it  must  be  accomplished  by 
restoring  the  nervous  system  first,  the  treatment  was  directed  to  that 
object.  Sleep  at  night  was  obtained  by  giving  thirty  grains  of  bro- 
mide of  sodium  late  in  the  afternoon,  and  half  an  ounce  of  whisky  at 
bed-time.  Aconitia,  one  two-hundredth  of  a  grain,  relieved  her  at- 
tacks of  neuralgia.  Massage  and  general  faradization  were  employed 
daily,  and  tonics  were  given,  consisting,  first,  of  valerianate  of  zinc, 
then  pyrophosphate  of  iron  and  arsenic,  and  then  iodide  of  iron. 

Citrate  of  iron  and  quinine  was  also  given  at  times.  The  form 
of  tonic  was  changed  whenever  she  becauie  used  to  that  which  she 
was  taking,  and  the  most  appropriate  diet  was  given.  Her  general 
health  improved  gradually,  and  in  the  summer  she  was  able  to  rest 
and  enjoy  life  in  the  country  by  the  sea.  Sea-bathing  was  also  tried 
after  a  time  with  benefit.  About  one  year  of  this  treatment  restored 
her  health,  but  the  menses  did  not  return.  In  fact,  the  restoration 
of  that  function  was  despaired  of  after  three  months'  treatment,  when, 
on  examination,  it  was  found  that  the  organs  of  generation  had  un- 
dergone complete  involution. 

Premature  Menopause  due  to  Chlorosis. — The  following  case  is 
taken  from  Tilt's  valuable  work  on  "  The  Change  of  Life."  The 
case  is  given  as  "  Chlorosis  mistaken  for  Cessation,"  but,  from  my 
way  of  looking  at  the  matter,  I  think  that  the  chlorosis  was  the  cause 
of  the  early  cessation  of  the  menstrual  function.  Chi  orotic  women 
are  liable  to  cease  menstruating  at  an  early  period,  and  frequently 
suffer  at  the  change  just  as  they  do  at  puberty.  Entertaining,  as  I 
do,  the  views  given  in  a  previous  chapter  on  chlorosis,  it  is  not  pos- 
sible for  me  to  believe  that  chlorosis  could  be  developed  at  the  meno- 
pause. It  is  a  condition  due  to  imperfect  development,  not  to  change 
in  structure : 

"  Case. — Annie  W.,  aged  thirty-three,  and  married,  had  an  ante- 
mic  hue  of  countenance.  The  menstrual  flow  first  came  at  thirteen ; 
had  been  regular  and  without  pain  until  tw^enty-oue,  when  she  mar- 
ried, and  had  one  child  at  twenty-four.  There  had  been  a  gradual 
diminution  of  the  menstrual  flow  for  the  previous  year,  with  intense 


428  DISEASES  OF   WOMEN. 

debility,  epigastric  faintness,  and  drenching  perspirations,  and  a  loud 
hi'ult  de  souffle  in  the  carotids.  Was  it  a  case  of  chlorosis  in  a  mar- 
ried woman  or  chlorosis  occurring  at  cessation  ?  I  inferred  the  latter 
from  the  gradual  failing  of  the  menstnial  flow,  and  the  pertinacity 
of  the  flushes  and  perspirations.  A  camphor-mixture,  a  hclladonna- 
plaster  to  the  pit  of  the  stomach,  and  sulphate  of  iron  in  pills,  cured 
the  patient,  and  when  I  saw  her  again,  three  years  afterward,  her 
health  was  good,  but  there  had  been  no  return  of  the  menstrual 
flow." 

The  Menopause  delayed  by  Fimgosities  of  the  Endometrium. — This 
patient  was  married,  and  the  mother  of  Ave  children.  After  the 
birth  of  her  last  child,  she  suffered  from  uterine  leucorrhoea,  proba- 
bly caused  by  endometritis.  She  had  fair  health  in  spite  of  that, 
and  menstruated  regularly  until  she  was  forty-six  years  old,  and  then 
the  menstrual  flow  became  more  profuse.  This  continued  intermit- 
tently for  nearly  one  year,  when  the  menses  came  more  frequently, 
lasted  longer,  and  the  flow  was  quite  profuse.  Her  heakh  failed 
gradually ;  she  became  anaemic,  weak,  low-spirited,  and  nervous. 
Though  her  flesh  remained  (she  was  rather  stout),  her  strength  was 
greatly  reduced.  Her  family  physician  gave  her  the  usual  remedies 
— lead  and  opium,  ergot,  cannabis  Indica,  and  aromatic  sulphuric 
acid — in  the  hope  of  controlling  the  flow,  but  without  effect. 

Finally  she  consented,  w^ith  some  reluctance,  to  an  examination, 
when  a  large  number  of  polypoid  growths  were  found  in  the  cavity 
of  the  uterus.  These  were  removed  with  the  curette,  and  the  flow- 
ing stopped  for  six  weeks ;  it  then  returned  for  a  few  days,  but  was 
not  very  free.  There  was  a  return  of  the  menstrual  flow  in  two 
months,  very  scanty,  and  another  in  three  months,  and  that  was  the 
end  of  it.  She  was  then  forty-eight  years  old.  After  the  removal 
of  the  fungous  growths  with  the  curette,  her  health  improved  under 
tonic  treatment,  and,  when  last  seen,  at  forty- nine  years  of  age,  she 
was  quite  well. 

Derangement  of  the  Ganglionic  Nervous  System  (from  Tilt). — Gan- 
GLioxic  HvPER-ESTUESiA. — Miss  C.  was  forty-eight,  tall,  stout,  with 
dark  hair,  and  a  flushed  face.  The  menstrual  flow  came  regularly 
from  thirteen  to  forty-seven,  then  irregularly,  being  often  a  mere 
show.  This  patient  had  never  been  nervous  or  hysterical,  and  she 
now  complains  of  pain  at  the  j)it  of  the  stomach,  which  first  appeared 
when  the  menstrual  flow  became  irregular,  and  says  that  she  is  never 
without  uneasy  sensations  at  the  epigastric  region,  which  do  not 
generally  interfere  with  her  occupations ;  but  paroxysms  of  acute 
pain  often  occur,  especially  at  night,  when  they  suddenly  awaken 


THE  MENOPAUSE.  429 

her  from  a  sound  sleep.  The  pain  tlien  experienced  is  described  as 
a  "  tearing  pain,"  and,  after  it  has  lasted  from  ten  to  twenty  minutes, 
ropy  mucus  comes  from  the  mouth,  by  expuition,  without  eructa- 
tions. When  the  intensity  of  the  pain  has  abated,  the  2:)atieiit  lies 
for  hours  conscious,  but  prostrate.  Sometimes  she  faints  after  a  bad 
attack ;  then  she  is  forced  to  keep  her  bed  a  day  or  two,  and  during 
the  last  six  months  flushes  and  perspirations  have  been  abundant. 
The  tongue  was  clean,  digestion  good,  and  no  trace  of  tumor  at  the 
pit  of  the  stomach.  I  had  six  ounces  of  blood  taken  from  the  arm, 
and  I  gave  two  tablospoonfuls  of  a  comp.  camphor  mixture  before, 
and  ten  grains  of  carbonate  of  soda  after  meals ;  two  comp.  col.  pills 
and  ten  grains  of  Dover's  powder  on  alternate  nights,  and  a  mustard 
or  a  linseed  poultice  was  applied  to  the  pit  of  the  stomach  every 
night.  The  camphorated  mixture  that  I  gave  in  such  cases,  before 
the  bromides  came  into  use,  was  composed  of  three  drachms  of  tinct- 
ure of  castor,  six  drachms  of  tincture  of  hyoscyamus,  and  five  ounces 
of  camphor  julep.  After  continuing  all  this  for  a  month,  the  par- 
oxysms came  only  once  a  week,  instead  of  almost  every  night ;  I  then 
ordered  a  warm  bath  to  be  taken  for  an  hour  every  night  just  before 
going  to  bed  ;  belladonna  and  opium  plasters  to  the  pit  of  the  stom- 
ach alternately  every  week,  and  a  scruple  of  sulphur  once  a  day. 
This  was  persisted  in  for  six  weeks,  and  was  then  left  off,  as  there 
had  been  no  paroxysms  for  ten  days.  When  the  patient  left  town, 
I  advised  her  to  take  the  mixture  should  she  feel  worse,  as  well  as 
the  pills  and  the  sulphur,  and  to  have  six  ounces  of  blood  again  taken 
from  the  arm  in  three  or  four  months.  This  case  seems  to  me  best 
accounted  for  by  admitting  a  neuralgic  affection  of  the  ganglionic 
nervous  center ;  for  the  stomach  performed  all  its  functions  health- 
ily, there  was  no  sign  of  cerebral  disorder,  neither  was  this  affection 
obscured  by  other  nervous  disorders.  It  caused  no  hysteria,  no 
pseudo-narcotism,  not  even  headache.  The  neuralgic  character  of 
the  case  was  well  marked  by  the  paroxysmal  outburst  of  the  pain, 
its  seat  in  the  central  ganglia  by  the  exhaustion  that  followed  tlie 
attacks. 

The  following  case  from  Tilt,  illustrates  another  of  the  same 
class  of  affections. 

Ganglionic  Dyssesthesia. — Sarah  B.,  tall,  stout,  and  healthy-looking, 
with  brown  hair  and  hazel  eyes,  was  forty-seven  when  she  came  to 
the  Paddington  Dispensary,  September  8,  1849.  The  menstrual 
flow  first  appeared  at  seventeen,  w^as  always  regular,  and  accompa- 
nied by  pseudo-narcotism.  She  married  at  twenty -five,  had  two 
children,  and  the  menstrual  flow  left  suddenly,  without  known  cause. 


430  DISEASES  OF  WOMEN. 

at  forty-four.  Since  tlieii  she  lias  been  entirely  free  from  lumbo- 
abdominal  pains,  but  has  suffered  much  from  other  nervous  symp- 
toms. There  has  been  no  headache,  but  a  heavy,  stujiid  feeling  in 
the  head,  with  drowsiness  in  the  day  after  sleeping  well  at  night, 
and  forgetfulness  of  familiar  things.  She  was  nervous,  desponding 
and  low-spirited  ;  often  shedding  tears,  and  had  strange  sensations  in 
the  throat.  Ever  since  cessation  she  had  been  distressed  by  a  flutter- 
ing at  the  pit  of  the  stomach,  "  as  if  something  were  perpetually 
swinging  within  her."  It  becomes  worse  after  meals,  generally 
abates  when  she  lies  down,  is  seldom  felt  when  in  bed,  but  begins 
as  soon  as  she  rises.  When  turning  the  corner  of  a  street,  this  sen- 
sation makes  her  feel  afraid  of  losing  her  center  of  stability  and  of 
overbalancing  herself ;  and  when  she  has  it  in  bed,  she  feels  "  as  if 
a  tub  were  rolling  to  and  fro  within  her,"  and  then  "  the  head  goes 
too,"  as  "  if  something  rose  from  the  pit  of  the  stomach  to  the 
head,  making  it  feel  giddy  and  bewildered."  Since  cessation,  she 
has  been  troubled  by  burning  flushes,  without  perspirations  ;  and 
there  is  sometimes  a  good  deal  of  pudendal  irritation.  There  was  no 
organic  disease  of  the  heart,  aortic  pulsation,  or  dyspeptic  condition 
to  explain  these  singular  symptoms ;  several  practitioners  have  told 
her  ''  it  was  all  nonsense  ; "  but  it  will  not  do  to  deny  a  patient's 
statement  because  sensations  can  not  be  explained.  I  ordered  the 
compound  camphor  mixture  before  meals  and  on  going  to  bed ;  car- 
bonate of  soda  after  meals ;  a  large  opium  plaster  to  the  pit  of  the 
stomach  ;  and  a  small  teaspoonful  of  sulphur  and  carbonate  of  mag- 
nesia over  night.  SejDtember  15th, — She  was  better ;  a  lead  lotion 
for  the  pudendal  irritation,  and  ten  grains  of  Dover's  powder  every 
night.  October  6th. — Instead  of  perspirations,  a  papular  eruption 
has  appeared  on  the  shoulders,  and  she  feels  rather  worse  than  bet- 
ter; but  the  remedies  were  continued,  with  the  addition  of  com- 
pound col.  pills,  to  be  taken  occasionally.  October  20th. — All  the 
cerebral  symptoms  have  vanished,  she  is  much  better,  and  can  bus- 
tle about ;  but  the  swinging  sensation  in  the  epigastric  region  still 
remains.  The  improvement  coincided  with  gentle,  well-sustained 
perspirations.  I  ordered  the  mixture  and  soda  as  before,  but  dis- 
continued the  sulphur  and  Dover's  powders  ;  prescribing,  instead, 
sulphur,  two  ounces ;  borax,  one  ounce ;  Dover's  powder,  one 
drachm  ;  two  scruples  of  the  powder  to  be  taken  in  a  little  milk,  at 
night.  A.  blister  was  ordered  to  the  pit  of  the  stomach.  Novem- 
ber 6th. — She  looks  cool  and  comfortable,  is  much  stronger,  and  is 
less  troul)led  by  the  swinging  sensation.  The  blister  did  no  good, 
so  I  ordered  a  rotation  of  belladonna  and  opium  plasters,  each  to  be 


THE  MENOPAUSE.  431 

worn  a  week  on  the  epigastric  region,  and  the  mixture  and  com- 
pound sulphur  powders  to  be  continued.  November  23d. — The 
patient  w^is  discharged  cured. 

Excrementitious  Plethora,  Oppression,  and  Derangement  of  the 
Nervous  System  from  the  Menopause. — A  strong-looking  German 
lady  gave  me  the  following  history  :  She  was  married  and  in  quite 
comfortable  circumstances.  She  had  six  children,  the  youngest  be- 
ing eleven  years  old.  Fi-om  the  time  of  her  last  confinement  her 
health  has  been  good  and  she  menstruated  normally,  until  she  was 
over  forty-six  years  of  age.  Her  menses  came  then  at  the  proper 
time  but  lasted  two  weeks  and  the  flow  was  too  free.  After  a  lapse 
of  three  months  the  menses  came  again  in  a  diminished  degree,  and 
again  in  two  months,  scantily.  From  the  time  of  her  free  menstru- 
ation, when  she  was  about  forty-six  years  old,  her  health  failed  grad- 
ually. She  had  always  been  a  generous  liver,  and  continued  to  take 
her  nourishment  well,  but  she  became  languid,  indisposed  to  exer- 
tion of  any  kind,  had  headaches,  was  drowsy  and  sleepy  all  the  time, 
but  often  had  restless  nights.  Her  mind  was  disturbed  so  that  she 
was  depressed  in  spirits,  quite  fretful,  did  and  said  "  queer  things  " 
which  alarmed  her  family,  and  her  memory  was  less  reliable  than 
formerly.  She  had  little  interest  in  her  former  duties  and  amuse- 
ments, but  occupied  her  time  mostly  in  thinking  and  talking  about 
her  feelings.  There  were  ilushings  of  the  face  at  times,  which  she 
described  as  rushing  of  blood  to  the  head,  which  she  fancied  might 
kill  her.  There  were  profuse  but  brief  paroxysms  of  perspiration, 
which  came  at  times  without  any  physical  exertion.  She  was  quite 
fleshy,  and  excepting  an  anxious  expression  of  the  face,  had  the  ap- 
pearance of  good  health.  The  tongue  was  coated,  the  bowels  con- 
stipated, the  urine  was  loaded  with  phosphates ;  the  pulse  fuU  but 
slow,  and  at  times  irregular;  the  appetite  was  not  good,  but  she 
took  food  in  abundance  and  drank  wine  and  beer  in  the  hope  of 
getting  strength.  She  suffered  from  labored  digestion  and  flatulence 
and  a  sense  of  fullness  in  the  region  of  the  stomach.  The  sexual 
organs  had  undergone  complete  involution  although  the  vagina  was 
relaxed  and  showed  some  venous  congestion. 

The  treatment  was  first,  ten  grains  of  blue-mass,  three  grains  of 
calomel,  and  one  grain  of  ipecac,  given  at  bed-time,  followed  in  the 
morning  with  a  dose  of  sulphate  of  magnesia.  This  was  repeated 
twice,  at  intervals  of  five  days,  and  after  that,  the  following  mixture 
was  given  :  Bromide  of  sodium,  half  an  ounce;  salicylate  of  sodium, 
two  drachms  ;  wine  of  colchicum-seeds,  two  drachms  ;  sirup  and 
water  enough  to  make  three  ounces,  and  a  teaspoonful  to  be  taken 


« 


432  DISEASES   OF  WOMEN. 

before  meals.  She  improved  very  much  on  this  treatment,  and  the 
mixture  was  contiuaed  for  about  six  weeks.  After  the  effects  of 
the  mercurial  cathartic  had  passed  off,  she  became  constipated,  and 
the  following  pill  was  given  at  bed-time.  Sulphate  of  quinine,  one 
grain  ;  extract  of  belladonna,  one  eighth  of  a  grain  ;  and  rhubarb, 
two  grains.  When  this  was  not  sufficient  to  move  the  bowels 
freely,  a  glass  of  Congress  water  was  given  an  hour  before  breakfast. 
Wine  and  beer  were  gradually  given  up,  and  her  diet  simplified  and 
reduced  in  quantity.  Exercise  in  the  open  air  was  prescribed,  and 
light,  agreeable  mental  occupation.  The  progress  of  the  case  was 
quite  satisfactory  for  about  two  months,  then  there  was  a  standstill 
for  a  time.  The  medicine  was  then  changed  to  a  mixture  of  hydro- 
chloric acid,  one  and  one  half  drachm  ;  tr.  nux  vomica,  one  and  one 
half  drachm  ;  tincture  of  cannabis  Indica,  two  drachms  ;  tincture  of 
cardamon,  one  ounce  ;  and  simple  sirup,  two  ounces  ;  one  drachm 
before  meals  in  water.  The  pill  at  bed-time  was  continued.  This 
last  prescription  was  given  for  about  two  months  with  an  interval  of 
three  days  after  each  bottle,  when  she  took  the  pill  only,  at  night. 
From  this  time  onward,  the  progress  of  the  case  was  steady  until 
she  Unally  recovered  her  former  good  health. 

Such  a  case  as  this  is  infrequently  seen  in  practice.  The  causes 
being  conditions  of  life  favoring  derangement  of  nutrition  and 
sluggish  disintegration,  aggravated  greatly  by  the  rather  abrupt  ces- 
sation of  the  menses. 

Impaired  Digestion  and  Assimilation  arising  from  the  Cessation  of 
Menstruation. — This  lady  was  married  and  the  mother  of  a  family, 
of  spare  habit  and  a  nervous  temperament,  but  her  health  had  been 
good  in  the  past.  When  she  was  forty  years  of  age,  her  menstrual 
flow  diminished  in  quantity  and  duration,  and  simultaneously  her 
appetite  failed,  and  she  lost  flesh  and  strength. 

Always  an  active  person,  she  now  became  restless,  nervous,  and 
irritable.  Her  tongue  was  clean,  but  of  a  deeper  color  than  normal, 
showing  that  rapid  exfohation  of  the  epithelium  was  going  on.  The 
bowels  were  constipated,  the  urine  was  abundant  and  of  light  color 
usually.  Her  skin  was  slightly  bronzed  and  usually  dry,  although 
she  had  occasional  outbursts  of  free  perspiration.  Her  pulse  was 
weak,  and  at  times  irregular.  Her  head  ached  quite  often  and  she 
had  wandering  pains  about  the  chest  and  abdomen.  Her  greatest 
trouble  was  a  feeling  of  distress  in  the  stomach  after  eating.  Eight 
months  from  the  time  that  the  menstrual  flow  began  to  decline,  it 
stopped  altogether,  and  two  months  afterward  I  first  saw  her. 

As  the  physical  condition  of  this  patient  was  almost  exactly  the 


THE  MENOPAUSE.  433 

opposite  of  the  preceding  case,  the  treatment  was  necessarily  very 
different.  She  was  directed  to  take  nutritious  food  in  small  quan- 
tity, six  times  a  day  ;  to  rest  as  much  as  possible  and  have  massage 
at  niglit,  which  gave  better  sleep. 

At  first,  she  was  given  five  grains  of  oxalate  of  cerium,  half  an 
hour  before  meals,  and  a  teaspoonful  after  meals,  in  warm  water, 
of  a  mixture  of  lactic  acid,  tincture  of  columbo,  and  pepsin  wine, 
and  she  improved  so  far  as  to  take  food,  and  digest  it  with  less 
trouble,  but  her  strength  did  not  return  as  fast  as  I  desired.  She 
was  also  constipated.  A  tonic  laxative  pill  was  then  given  before 
meals  consisting  of  quinine,  belladonna,  and  compound  extract  of 
colocynth  ;  and  after  meals,  she  was  given  a  teaspoonful  of  whis- 
ky with  four  drops  of  tincture  of  nux  vomica  and  four  grains  of 
animal  charcoal.  This  appeared  to  help  her,  and  this  course  of 
tonic  treatment  was  continued  very  faithfully  for  three  months, 
when  she  considered  herself  sufficiently  well  without  further  treat- 
ment. 

Two  years  afterward  she  was  found  to  be  in  good  health. 

Circumscribed  Infiammation  of  the  Vagina  and  Cervix  Uteri,  partly 
due  to  the  Menopause. — The  patient  was  first  seen  when  she  was 
forty-eight  years  old.  The  menses  had  stopped  one  year  and  two 
months  before.  Her  health  was  fairly  good  and  always  had  been, 
but  for  some  time  before  the  menopause  and  all  the  time  after,  she 
had  been  distressed  by  a  discharge  from  the  vagina  of  sero-purulent 
but  rather  tenacious  material,  which  caused  some  external  irritation. 
There  was  heat  and  burning  in  the  pelvis  which  became  more 
marked  on  walking.  She  had  put  up  with  her  troubles  so  long,  be- 
lieving that  it  was  due  to  change  of  life  and  would  pass  off  in  time. 
I  In  fact,  she  had  been  told  this  by  her  physician.  But,  instead  of 
disappearing,  she  found  that  the  trouble  increased,  if  indeed  it 
changed  at  all.  Her  general  health  was  below  par  considerably, 
but  there  was  no  organic  disease  of  the  organs  of  nutrition,  and  yet 
ultimate  nutrition  was  a  little  sluggish. 

The  sexual  organs  had  undergone  final  involution  ;  the  uterus 
was  small,  but  the  os  externum  was  open,  and  coming  from  the 
canal  was  a  tenacious,  darkish-colored  discharge,  not  unlike  the  leu- 
corrhosa  found  in  young  subjects  and  heretofore  described  under  the 
head  of  "  Cervical  Endometritis  in  the  Imperfectly  Developed 
Uterus." 

The  mucous  membrane  about  the  external  os  was  eroded  in 
patches,  and  on  the  anterior  lip  of  the  cervix  there  were  some  granu- 
lar spots  that  looked  as  if  they  were  the  products  of  epithelial  hy- 
29 


434  DISEASES   OF   WOMEN. 

perplasia.  The  appearance  of  the  vagina  was  peculiar.  In  place  of 
the  general  congestion  of  a  well-marked  vaginitis,  the  mucous  mem- 
brane was  studded  with  small  red  points  or  patches,  while  the  inter- 
vening portions  of  the  membrane  were  pale.  The  surface  of  the 
membrane  was  covered  with  a  sero-purulent  discharge  ;  at  the  vulva 
there  were  several  patches  of  congestion  larger  than  those  higher  up 
in  the  vagina.  Some  of  these  were  of  a  deep-red.  and  slightly  bhi- 
ish  color. 

The  thought  came  to  me  that  this  might  be  malignant  diseaj^e  of 
the  cervix  just  beginning,  but  this  was  put  aside,  because  of  the 
duration  of  the  trouble  and  the  fact  that  I  have  several  times  seen 
this  condition  after  the  menopause. 

I  have  also  frequently  seen  the  same  conditions  in  young  insane 
women  who  had  amenorrhoea.  These  facts  led  me  to  suppose  that 
the  inflammatory  action  was  due  to  impaired  nutrition  which  is  pres- 
ent at  the  involution  of  the  sexual  organs.  This  low  grade  of  in- 
flammatory action  is  no  doubt  more  likely  to  occur  in  those  who 
have  had  some  ordinary  cervical  endometritis  and  vaginitis  before 
the  menopause.  The  circumscribed  red  spots,  looked  to  me  like  a 
few  live  coals  here  and  there  in  the  ashes  left  after  the  flres  of 
functional  life  and  inflammation  had  subsided. 

The  treatment  consisted  of  general  tonics  and  local  astringents, 
citrate  of  iron  and  quinine  was  given  interaally,  and  a  teaspoouful 
of  sulphate  of  zinc  in  a  quart  of  water  for  a  vaginal  douche. 

The  parts  about  the  os  externum  were  touched  once  with  a  flfty- 
per-cent  solution  of  chloride  of  zinc.  The  sulphate-of-zinc  injec- 
tions did  very  well  for  a  time,  but  the  progress  was  favored  by  an 
occasional  application  of  glycerin  and  tannic  acid. 

The  local  improvement  did  not  surpass  the  general  regaining  of 
strength,  but  kept  pace  with  it.  The  recovery  was  permanent  and 
perfect. 

Pelvic  pains  of  a  neuralgic  character  are  common  about  the 
change  of  life,  and  are  often  due  to  it.  The  following  two  cases 
from  Tilt  will  illustrate  this  form  of  trouble. 

Ovario-XJterine  Neuralgia. — Miss  X.,  was  forty-seven  when  she 
first  consulted  me.  She  is  small,  but  well-proportioned ;  has  been 
highly  nervous  all  her  life.  Menstruation  was  irregular,  and  tliere 
was  a  muco-purulent  discharge,  vaginitis,  and  decided  ulceration  of 
the  cervix,  and  a  most  irksome  sensation  of  heat  and  irritation  in  the 
passage.  I  cured  the  vaginitis  and  ulceration  by  surgical  measures, 
without  relieving  the  vaginal  heat  and  pruritus,  so  I  sent  the  patient 
out  of  town.     When  she  returned,  after  many  months,  the  pruritus 


THE  MENOPAUSE.  435 

'  was  as  bad  as  ever,  and  would  come  on  after  any  excitement  or 
fatio-nc,  or  standing  about,  and  would  be  relieved  by  resting  with  the 
feet  higher  than  the  pelvis.  This  vulvo-vaginal  irritation  would 
sometimes  disappear  on  the  coming  on  of  a  similar  pruritus  on  the 
palms  of  the  hands  and  on  the  soles  of  the  feet,  showing  that  how- 
ever much  the  chief  seat  of  neuralgia  might  be  in  the  womb  or  va- 
gina, the  ultimate  nervous  expansions  in  other  parts  of  the  body 
mio^ht  similarly  suffer.  When  this  irritation  affects  the  feet  and 
hands  there  is  nothing  to  be  seen  there,  and  she  refrains  from  scratch- 
ino-  them  because  it  would  prolong  the  irritation  for  hours.  As 
might  have  been  predicted,  the  symptoms  were  worse  at  night,  and 
led  to  great  exhaustion  and  despondency.  I  have  watched  this  state 
of  things  for  twenty  years,  and  at  times  could  give  no  relief.  She 
was  always  better  for  plenty  of  food  and  wine,  and  for  such  small 
quantities  of  citrate  of  iron  and  quinia  as  she  could  bear.  I  tried 
all  sorts  of  injections  ;  tar-water  did  most  good,  but  it  has  been  re- 
peatedly advisable  to  leave  off  all  kinds  of  injection,  for  they  seemed 
to  do  more  harm  than  good.  I  syringed  the  vagina  with  a  solution 
of  nitrate  of  silver  and  touched  the  passage  with  the  solid  caustic, 
with  questionable  benefit.  A  rectal  suppository,  containing  a  grain 
of  opium  and  one  of  extract  of  belladonna  often  gave  temporary  re- 
lief, but  this  remedy  could  not  be  relied  on.  By  the  sacrifice  of  her 
own  health  many  a  daughter  has  well  repaid  the  gift  of  life ;  and 
when  my  patient  lost  her  mother,  who  had  been  long  a  cripple,  re- 
quiring anxious  and  fatiguing  nursing,  she  went  out  of  town  and  got 
fat,  and  now  suffers  much  less,  only  having  a  slight  return  of  the 
old  symptoms  when  she  gets  weaker  and  more  nervous. 

Ovario-Xrterine  Neuralgia. — A  very  strongly-constituted  lady,  aged 
forty-seven,  is  said  to  have  had  some  acute  uterine  disease  twenty 
years  ago,  while  residing  in  France,  when  forty  leeches  were  ap- 
plied above  the  pubis.  With  the  exception  of  not  being  able  to  re- 
tain the  urine  so  well  as  previously  to  this  attack,  health  remained 
so  good  that  every  year  she  was  able  to  take  long  pedestrian  excur- 
sions with  her  husband.  She  never  conceived,  and  menstruation 
ceased  suddenly  at  forty-four;  in  the  following  months  the  nose  bled 
very  frequently,  and  the  bowels  became  constipated  ;  for  which  she 
went  to  Homburg  and  was  restored  to  health.  On  returning  to 
town,  in  December,  1868,  she  took  very  cold  enemata,  for  constipa- 
tion, which  was  so  great  that  a  wineglass  of  Friedrichw^hall  water, 
taken  every  hour,  failed  to  produce  watery  motions,  and  only  irri- 
tated the  bladder,  apparently  causing  the  strange  abdominal  sensa- 
tions which  have  lasted  ever  since.     The  patient  feels  as  if  there  were 


436  DISEASES  OF   WOMEN. 

a  heavy  body  in  tlio  pelvis,  bearing  down  upon  the  rectum,  with  a 
burning  sensation,  referred  Bonietinies  to  that  organ,  Kunietinies  t(j 
the  vagina,  or  to  the  bladder.  When  in  bed  and  lying  down,  with 
the  feet  up,  she  feels  comfortable ;  by  the  time  she  has  half  done 
dressing  the  burning  sensation  begins,  and  la.sts  until  the  buwels 
have  been  moved  ;  soon  after  this  the  burning  comes  back  ;  it  is  ag- 
gravated by  standing  or  sitting,  by  indigestion,  flatulence,  constipa- 
tion, and  repletion  of  the  bladder ;  also  by  worry  and  bad  news. 
The  sensation  is  relieved  by  moderate  walking,  by  lying  down,  and 
by  regularity  of  the  bowels,  llomburg  was  again  tried  ;  it  did 
good,  but  on  her  return  the  lady  was  as  bad  as  before,  and  consulted 
several  doctors.  One  attributed  the  sufferings  to  stricture  of  the 
rectum,  another  to  irritation  of  the  bladder,  a  third  to  displacement 
of  the  womb.  The  following  summer  llomburg  was  tried  for  a 
third  time,  but  the  waters  were  soon  left  off,  for  they  aggravated  all 
the  symptoms,  and  after  the  patient's  return  to  town  Dr.  ]3eale  sent 
her  to  me.  In  addition  to  the  pelvic  symptoms  already  described  a 
strong-minded,  sharp,  matter-of-fact  woman  was  in  a  state  of  mental 
confusion ;  her  brain  felt  muddled,  and  she  would  sit  for  hours  doz- 
ing or  doing  nothing ;  despondency  l)eing  doubtless  increased  by 
finding  herself  helpless  as  a  child,  after  having  passed  all  her  life  in 
doing  everybody  else's  business  as  well  as  her  own.  She  forgot 
where  she  put  things  ;  once  thought  she  had  taken  out  a  large  sum 
of  money  in  her  purse,  and  that  she  had  lost  it,  whereas  a  month 
afterward  she  found  it  in  some  out-of-the-wa}'  place.  On  examin- 
ing, I  found  the  rectum  perfectly  healthy,  notwithstanding  the  j^ain 
and  stricture  ascribed  to  it.  I  was  given  to  understand  that  marriage 
had  never  been  concluded,  and  the  vagina  was  so  narrow  that  I  could 
with  difficulty  introduce  part  of  my  index-finger ;  so  I  ordered  lin- 
seed tea  and  laudanum  injections,  three  times  a  day,  and  henbane 
internally.  A  few  days  afterward  I  was  able  to  reach  the  os  uteri ; 
I  found  the  womb  exquisitely  sensitive;  and  on  sounding  the  blad- 
der there  was  nothing  abnormal,  except  great  pain  when  the  sound 
passed  over  the  uretlira^  the  pain  not  being  caused  by  inflammation, 
for  the  finger  in  the  vagina  did  not  feel  the  urethra  as  a  hard  and 
round  body  painful  on  being  pressed.  Injections  with  acetate  of 
lead  and  laudanum,  as  well  as  opium  and  belladonna  rectal  siijiposi- 
tories,  enabled  me,  a  little  later,  to  examine  the  womb  without  giv- 
ing pain ;  there  was  no  ulceration  and  there  had  been  little  vaginal 
discharge.  The  pain  was  most  felt  at  the  o]>ening  of  the  vagina, 
which  looked  sore,  red,  and  injected,  a  condition  that  accounted  for 
a  very  unusual  hardness  of  the  recto- vaginal  tissues,  a  hardness  of 


THE  MENOPAUSE.  437 

which  the  patient  was  sensible,  and  complained  of  as  something 
wrong  with  "  the  bridge."  This  was  caused  by  long-continued  con- 
gestion, although  the  parts  were  then  without  heat  or  redness.  This 
sore  state  of  the  vaginal  opening  was  relieved  by  the  apj^lication 
twice  a  day,  of  zinc-ointment,  to  each  ounce  of  which  was  added  a 
di'achm  of  diluted  hydrocyanic  acid.  Vaginitis  becoming  worse,  I 
swabbed  the  vagina  once  a  week  with  a  solution  of  nitrate  of  silver, 
and  I  ordered  alum  and  zinc  injections ;  suppositories  did  harm, 
whether  administered  by  the  vagina  or  the  rectum.  After  thus 
treating  the  patient  for  a  few  months,  the  sensations  of  burning  and 
weigiit  had  considerably  diminished,  but  were  often  troublesome. 
Digestion  was  much  improved  by  nitro-muriatic  acid  and  pepsin ; 
pseudo-narcotism  and  mental  disturbance  were  not  relieved  by  bro- 
mide of  potassium,  but  were  much  reduced  by  henbane  and  Indian 
hemp;  and  then  the  patient  took,  for  two  months,  three  times  a 
day,  at  meals,  the  twenty-fourth  of  a  grain  of  arseniate  of  iron, 
made  into  a  pill  with  a  fourth  of  a  grain  of  Indian  hemp — a  combi- 
nation suitable  alike  to  the  general  nervous  derangement  and  to  the 
abdominal  neuralgia.  This  leads  me  to  the  question  of  diagnosis. 
There  was  no  organic  disease  of  the  bladder  or  rectum,  nor  of  the 
womb,  neither  displacement  nor  ulceration  of  this  organ.  The  dis- 
ease originated  in  vaginitis,  kept  up  by  excessive  walking  and  drastic 
medicines,  at  the  change  of  life.  The  vaginitis  causing  neuralgia  of 
both  the  sensory  and  the  ganglionic  pelvic  nerves,  the  neuralgia 
causing  pseudo-narcotism  and  the  other  forms  of  cerebral  disturb- 
ance that  usually  attend  the  menopause ;  the  neuralgic  element  of 
the  case  being  shown  by  the  patient's  often  feeling  the  disturbance 
to  ascend,  as  it  were,  from  the  pelvis  along  the  spinal  column  to  the 
back  part  of  the  head,  where  there  was  most  suffering.  There  was 
a  gradual  recovery  of  health,  and  this  patient  has  been  able  to  re- 
sume her  usual  very  active  life. 

A  long  list  of  diseases  has  been  given  as  occurring  at  the  meno- 
pause. This  list  covers  nearly  all  the  ills  that  flesh  is  heir  to.  The 
majority  of  these  have  no  relations  to  the  menopause  excepting  that 
when  there  is  a  predisposition  to  any  disease,  the  disturbances  of  the 
system  due  to  the  change,  would  favor  the  outbreak  at  that  time. 

No  notice  need  be  taken  of  those  affections  which  are  common 
to  all  periods  of  life,  the  menopause  only  determining  the  time  of 
their  development.  When  there  exists  a  predisposition  to  any  of 
the  constitutional  diseases,  the  condition  of  nutrition  at  the  meno- 
pause, and  the  disturbed  or  unbalanced  state  of  the  nervous  system, 
favor  the  outbreak  of  these  morbid  tendencies. 


CHAPTER  XXIY. 


DISEASES   or   TnE   OVARIES. 


THE   ANATOMY   AND   PHYSIOLOGY  OF   THE   OVARY. 

The  ovaries  are  two  bodies,  in  shape  somewhat  like  an  almond, 
situated  in  the  pelvic  cavity,  one  on  either  side  of  the  utenis,  and 
removed  from  it  about  one  inch.  They  are  connected  with  tliat 
organ  by  the  Fallopian  tubes  and  the  ovarian  ligaments.  Before 
birth  the  ovaries  are  on  a  level  with  the  iliac  fossa,  and  it  is  not  until 
the  tenth  year  of  life  that  they  reach  what  may  be  considered  their 
permanent  position — that  is,  the  lateral  and  posterior  part  of  the 
true  pelvis.  Hasse,  of  Breslau,  in  a  female  cadaver  frozen  in  the 
upright  position  found  that  the  long  axis  of  both  ovaries  ran  out- 
ward and  forward,  form- 
ing wdth  the  transverse 
axis  of  the  uterus  an  an- 
gle open  to  the  front, 
with  one  half  of  the  or- 
gan projecting  above  the 
plane  of  the  pelvic  brim. 
Schultze,  on  the  contrary, 
regards  the  long  axis  of 
the  ovaries  as  being  in 
an  antero-posterior  posi- 
tion, as  shown  in  Fig. 
185.  It  must  be  borne 
in  mind,  however,  that 
the  position  of  tlie  ovaries  is  not  a  fixed  one  ;  their  relation  to  the 
uterus  and  the  other  pelvic  organs  is  such  that,  when  any  one  of 
these  is  displaced,  a  change  in  the  position  of  the  ovaries  will  of 
necessity  occur ;  thus  the  full  or  empty  bladder  or  rectum  acting 
upon  the  uterus  will  tend  to  push  the  ovaries  in  one  direction  or 
another. 


Fig.  185. — The  fundus  uteri  and  ovaries  seen  through 
the  pelvic  brim  (His).  The  cross  is  in  the  center 
of  the  pelvis  and  on  the  fundus ;  o,  o,  ovaries 
encircled  by  the  J^allopian  tubes  in  their  backward 
sweep. 


DISEASES   OF  THE   OVARIES.  439 

The  average  dimensions  of  each  ovary  are :  Length,  one  inch  and 
a  quarter  ;  width,  three  quarters  of  an  inch ;  and  thickness,  half  an 
inch.  Its  weight  is  about  eighty  grains.  As  its  position  changes, 
so  do  also  the  measurements  here  given.  It  is  probably  in  its  most 
perfect  condition  in  the  virgin  at  about  the  age  of  puberty.  Ac- 
cording to  Ilennig's  observations,  the  ovary  increases  in  length  dur- 
ino"  pregnancy,  but  neither  its  breadth  nor  thickness  exceeds  that 
found  in  the  virgin.  When  pregnancy  has  ceased,  the  ovaries  become 
smaller,  and  do  not  at  any  time  subsequently  regain  the  diinensions 
possessed  by  the  virgin  ovary. 

Tiie  relation  of  the  ovaries  to  the  broad  ligament  is  a  matter  of 
great  importance  and  interest.  These  ligaments  consist  of  two  folds 
or  layers  of  the  peritonaeum,  with  a  lining  of  muscular  tissue,  be- 
tween which  lie  the  uterus  and  its  appendages.  The  ovaries,  how- 
ever, are  not  situated  between  these  two  layers,  but  are  suspended, 
so  to  speak,  from  the  posterior  surface  of  the  posterior  layer,  and 
are,  therefore,  entirely  behind  both  layers  or  folds  of  peritonseum, 
which  form  the  broad  ligament,  but  attached  to  the  posterior  layer 
by  their  long  axis,  this  attached  portion  of  the  ovary  being  termed 
the  hilum.  In  the  anterior  face  of  the  posterior  layer  of  the  broad 
ligament,  on  either  side,  is  an  opening  or  slit  through  which  the 
blood-vessels,  nerves,  and  lymphatics  of  the  ovary  pass.  The  ovarian 
ligaments  which  connect  the  body  of  the  uterus  and  the  ovaries, 
leaving  the  former  at  a  point  between  the  Fallopian  tubes  and  the 
round  ligaments,  after  running  for  some  distance  between  the  two 
layers  of  the  broad  ligament,  pass  out  by  these  openings  in  the  pos- 
terior layers  to  the  ovaries.  These  ovarian  ligaments  are  about  one 
inch  in  length,  and  are  composed  of  fibrous  tissue,  into  which  some 
of  the  uterine  muscular  tissue  is  prolonged  (Fig.  18G).  Each  ovary 
is  also  connected  with  the  corresponding  Fallopian  tube  by  one  of 
its  iimbrise,  and  through  this  to  the  pelvis  by  means  of  the  infundib- 
ulo-pelvic  ligament — a  ligament  about  two  thirds  of  an  inch  in 
length,  running  from  the  outer  end  of  the  Fallopian  tube  to  the  wall 
of  the  pelvis.  Thus  the  ovary  is  maintained  in  its  position — subject, 
however,  to  considerable  alteration — by  the  broad,  the  ovarian,  and 
the  infundibulo-pelvic  ligaments. 

The  supply  of  blood  to  the  ovaries  is  by  the  ovarian  artery,  a 
branch  of  the  abdominal  aorta,  corresponding  to  the  spermatic  artery 
of  the  male. 

After  this  artery  enters  the  pelvis,  it  passes  between  the  layers 
of  the  broad  ligament  in  a  direction  toward  the  upper  angle  of  the 
uterus ;  its  course  is  parallel  to,  though  below,  the  Fallopian  tube. 


440 


DISEASES  OF   WOMEN. 


It  seuds  branches  to  the  ovary,  which  pass  out  fi'oin  between  tlie 
layers  of  the  broad  ligament  to  the  ovary  through  the  opening  in 


Fig.    186. — The   ovary  and   its   ligaments  (Henle).      it,  uterus;     Od,  Fallopian  tube  ;| 
lo,  ovarian  ligament ;  ip,  infundibulo-pelvic  ligament ;  io,  iufundibulo-ovariau  liga 
ment ;   Fo,  fimbria  ovarica  ;  Fo,  parovarium. 

the  posterior  layer  already  referred  to.  Other  branches  supply  the 
Fallopian  tube  and  anastomose  with  the  uterine  artery.  The  venoi 
blood  of  the  ovary  passes  into  the  ovarian  plexus,  sometimes  spoke 
of  as  the  pampiniform  plexus,  which  is  situated  between  the  layers! 
of  the  broad  ligament,  and  is  thence  carried  to  the  inferior  vena  cava 
on  the  right  side,  and  to  the  renal  vein  on  the  left.  These  veins,] 
which  form  a  network  in  the  ovary,  have,  according  to  Rouget,  as-j 
sociated  with  them  muscular  trabeculae,  which,  in  their  contraction,] 
prevent  the  passage  of  the  blood  from  the  ovary  into  the  large  venous] 
trunks,  and  thus  permit  of  what  may  be  termed  an  erection  of  the] 
ovary.  It  is  probable  that  during  the  act  of  coition  such  a  condition] 
takes  place  in  the  ovary,  increasing  its  size  to  a  considerable  extent,] 
and  causing  it  to  become  firmer  and  more  sensitive.  liouget  de-j 
scribes  the  lymphatics  of  the  ovary  as  united  into  six  or  eight  trunks,] 
which  accompany  the  ovarian  artery,  and  discharge  into  the  middle] 
and  superior  lumbar  lymphatic  ganglia.  The  lymphatic  circulation] 
becomes  of  special  importance  in  explaning  the  method  by  which,] 
under  certain  conditions,  septic  matter  is  absorl)ed,  producing  sep-l 
ticsemia.  The  ovarian  and  uterine  plexuses  comnninicate,  as  do  thoj 
arteries  of  the  same  names. 


DISEASES  OF  THE  OVARIES. 


441 


The  nerves  of  the  ovaries,  as  well  as  those  of  the  ntenis,  arise 
iSL  ca^liac  plexus,  which  is  in  part  distributed  to  the  ovaries 


Fig.  187.- 


-The  ovarian,  uterine  and  vaginal  arteries  (Hyrtl). 


and  to  tl>e  spermatic  ganglia.  According  to  ^-"-^^^^^^ 
superior  mesenteric  plexus  supplies  these  ^f  ™^t,c  gangl  a  .h>A 
Conrty  suggests  wonld  be  better  called  gemtal  ganglia.  These  gan 
.ha,  our  fn  nnmber,  are  supplied  from  the  sympathetic  through  two 


442  DISEASES  OF   WOMEN. 

large  hranclics,  and  in  turn  supply  the  ovaries  through  a  considerable 
nunil)er  of  liranciies. 

Development  of  the  Ovary. — At  a  very  early  period  in  the  devel- 
opment of  the  f(L'tiis,  two  bodies  are  formed  in  the  abdominal  cavity, 
one  on  each  side  of  the  spinal  column  ;  these  are  the  WoltHan  bodies, 
the  function  of  which  is  undoubtedly  similar  to  that  of  the  adult 
kidney.  According  to  Coste,  they  are  fully  formed  at  the  end  of 
the  first  month,  and,  according  to  Longet,  are  hardly  visible  after 
the  second  month.  While  these  organs  are  in  a  state  of  activity, 
the  kidneys  are  formed  behind  them,  and  at  the  same  time  two  other 
organs  appear  in  front  of  the  Wolfhan  bodies,  and  on  their  inner 
side ;  these  are  the  internal  organs  of  generation — the  testicles  in  the 
male  and  the  ovaries  in  the  female.  The  detailed  history  of  the 
development  of  these  organs  is  as  follows  :  At  a  very  early  stage  of 
development — in  the  chick  as  early  as  the  third  day — the  cells  of 
the  mesoblast  form  a  longitudinal  cord  in  the  mesoblast,  one  on  each 
side  of  the  body,  and  just  external  to  the  ])roto vertebrae,  which  are 
also  formed  from  this  same  layer.  These  cords  are  at  first  solid,  but 
a  cavity  gradually  forms  within  them,  and  they  become  the  Wolffian 
ducts.  From  this  primitive  tube  diverticula  are  given  off,  forming, 
as  it  were,  blind  tubes,  into  which  blood-vessels  enter,  and  with  the 
diverticula  form  the  Wolffian  bodies,  one  upon  either  side.  Another 
portion  of  the  mesoblast  projecting  in  the  form  of  a  ridge,  and  cov- 
ered with  "  germ  epithelium  "  on  the  inner  side  of  the  Wolffian  body 
— that  is,  toward  the  median  line — becomes  the  testicle  or  the  ovary, 
according  as  the  individual  is  to  be  of  the  male  or  female  sex.  On 
the  outer  wall  of  the  Wolffian  body  an  involution  takes  place  from 
the  pleuro-peritoneal  cavity,  forming  at  first  a  furrow,  but  later,  by 
the  union  of  its  edges,  a  duct,  which  is  known  as  Miiller's  duct.  In 
the  female  these  ducts  form  the  Fallopian  tubes,  the  uterus,  and  the 
vagina,  while  in  the  male  they  have  no  special  function,  although 
the  upper  part  remains  as  the  hydatid  of  Moi-gagni,  and  the  lower 
as  the  prostatic  pouch,  the  uterus  masculinus,  or  sinus  jjocularis. 
While  the  Wolffian  ducts  in  the  male  form  the  body  and  globus 
minor  of  the  epididymis,  the  vas  deferens,  and  the  ejaculatory  duct, 
in  the  female  the  lower  part  only  remains  to  form  the  duct  of  Gaert- 
ner.  If  the  broad  ligament  is  examined  with  transmitted  light,  a 
cone,  nearly  an  inch  in  Ijreadth,  of  whitish,  more  or  less  convoluted 
tubes  are  seen,  in  number  about  twenty,  each  of  which  is  lined 
with  ciliated  epithelium,  and  contains  a  clear  fluid  (see  Fig.  188). 
This  is  the  parovarium  of  Kobelt,  or  the  organ  of  Rosenmuller, 
and  is  the  remnant  of  the  Wolffian  body  of  fetal  life.     The  path- 


DISEASES   OF  TOE   OVARIES.  443 

olo-ical  degeneration  of  these  tubes  produces  the  parovarian  cystic 


tumor. 


Minute  Anatomy  of  the  Ovary. -The  fact  that  the  ovary  is  situ- 
ated behind  both  layers  of  tlie  broad  hgament,  and  attached  only  at 


the  hilum,  has  already  been  referred  to.  From  this  it  follows  that 
the  posterior  surface  of  the  ovary  is  not  covered  by  peritoneum. 
The  more  thorough  and  skillful  investigations  of  recent  years  have 
satisfactorilv  demonstrated  that  the  surface  of  the  ovary  ^^  i"  ^PP^^];; 
ance  and  structure  very  different  from  the  peritonaeum.  ^^  hi  e  the 
epithelium  which  covers  the  broad  ligament  is  transparent  and  flat- 
tened, that  which  forms  the  surface  of  the  ovary  is  granular  m  ap- 
pearance and  columnar  in  form.     This  marked  difference  has  sug- 


444  DISEASES  OF   WOMEN. 

gested  to  some  tliat  the  covering  of  the  ovary  was  a  mucous  rather 
tJian  a  serous  membrane.  These  columnar  cells  are  very  similar  to 
those  lining  the  Fallopian  tubes,  except  that  the  cilia  which  are 
])resent  in  the  latter  are  wanting  in  the  former.  It  is  an  error  to 
regard  these  supertlcial  cells  of  the  ovary,  which  are  arranged  in  a 
single  layer,  as  in  any  sense  a  covering  of  the  ovary.  They  are  in 
reality  an  integral  part  of  the  ovary,  and,  as  the  name  "germ  epi- 
thelium" implies,  their  function  is  a  most  important  one,  being 
none  less  than  the  formation  of  the  ova  by  a  modification  of  their 
structure,  as  has  been  so  well  described  by  Waldeyer. 

Beneath  this  layer  of  germ  epithelium  is  the  tunica  albuginea. 
This  is  made  up  of  bundles  of  spindle-shaped  cells,  an-anged,  accord- 
ing to  Ilenle,  in  three  layers,  the  outer  and  inner  ones  being  longi- 
tudinal, and  the  middle  one  circular.  The  albuginea  contains  no 
Graafian  follicles.  The  third  layer — that  is,  the  one  next  to  the 
albuginea — is  what  Schron  has  described  as  the  cortical  layer.  This 
contains  the  smallest  of  the  Graafian  follicles  arranged  in  groups, 
but  separated  by  the  stroma  of  the  ovary,  this  latter  being  made  up 
of  bundles  of  spindle-shaped  cells,  some  short  and  others  long,  each 
having  an  oval  nucleus,  and  being  jDrobably  young  connective-tissue 
cells.  The  Graafian  follicles  of  the  cortical  layer  are  spherical  or 
shghtly  oval  bodies,  with  a  diameter  of  one  one  thousandth  of  an  inch, 
and  have  as  their  external  poition  a  delicate  membrane — the  mem- 
brana  propria.  Lining  this  is  the  membrana  granulosa,  a  layer  of 
flat,  transparent,  epithelial  cells,  with  oval  nuclei.  "Within  this,  and 
occupying  the  entire  cavity  of  the  follicle,  is  a  spherical  cell — the 
o^'um.  The  ovum  is  a  collection  of  granular  protoplasm  containing 
a  spherical  or  oval  nucleus,  the  germinal  vesicle,  and  this,  in  turn,  a 
body  knowai  as  the  germinal  spot.  Below  this  cortical  layer,  im- 
bedded in  the  stroma,  are  Graafian  follicles  of  almost  every  conceiva- 
ble size.  While  the  older  anatomists  thought  the  total  number  of 
follicles  in  an  ovary  did  not  exceed  twenty,  this  number  being  all 
that  could  be  seen  by  the  unaided  eye,  some  of  the  more  recent 
authorities  have  placed  the  number  at  six  hundred  thousand.  As 
follicles  rupture  and  discharge  each  month  for  a  long  series  of  years, 
the  estimate  of  the  earlier  writers  is  undoubtedly  too  low — probably 
as  much  too  low  as  that  of  some  of  the  recent  ones  is  too  high.  All 
the  layers  thus  far  described  constitute  the  parenchyma  of  the  ovary. 
Between  this  and  the  liilum  is  the  vascular  zone,  which  contains  no 
follicles,  but  is  made  up  of  bundles  of  connective  tissue  and  bundles 
of  non-striped  muscular  tissue,  which  are  directly  continuous  with 
the  corresponding  tissues  of  the  broad  ligament.     It  is  in  this  vas- 


DISEASES   OF   TUE   OVARIES.  445 

cular  zone  that  the  blood-vessels  of  the  ovary  are  found,  and,  indeed, 
give  to  it  the  name  which  characterizes  it. 

The  Graafian  follicle  of  medium  size  is,  like  that  of  the  cortical 
layer,  made  up  of  a  membrana  propria  and  a  membrana  granulosa, 
and  contains  an  ovum.  The  ovum  is,  however,  larger  than  that  of 
the  cortical  follicles,  and  is  limited  by  a  thin  membrane,  the  zona 
pellucida  or  vitelline  membrane.  This  is  believed  to  be  formed  by 
the  cells  of  the  membrana  granulosa.  As  the  follicle  increases  in 
size  the  ovum  does  not  increase  correspondingly,  so  that,  while  for 
a  considerable  time  it  completely  tilled  the  cavity,  now  it  does  not 
do  so,  and  the  space  between  it  and  the  membrana  graimlosa  contains 
an  albuminous  iiuid — the  liquor  folliculi.  It  should  be  stated  that 
a  Graaiian  follicle,  while  it  usually  contains  but  one  ovum,  does  some- 
times contain  two  or  even  three  ova.  At  one  part  of  the  membrana 
granulosa  the  cells  are  more  abundant  than  elsewhere,  forming  a 
mound  which  is  known  as  the  discus  or  cumulus  proligerus ;  in  the 
center  of  this  accumulation  of  cells  the  ovum  is  imbedded.  Some  of 
the  Graafian  follicles  reach  maturity,  so  far  as  can  be  told  from  their 
size  and  appearance,  and  undergo  degeneration  before  the  age  of 
puberty  is  attained.  Some  of  the  small  follicles  also  degenerate, 
never  reaching  maturity.  The  number  of  follicles  which  thus  de- 
generate is  by  no  means  inconsiderable,  and  a  knowledge  of  this  fact, 
and  that  at  each  menstrual  epoch  a  follicle  ruptures,  leads  us  to  be- 
lieve that  the  total  number  of  follicles  in  an  ovary  must  be  reckoned 
by  thousands. 

Development  of  the  Graafian  Follicles  and  Ova. — Having  described 
the  minute  anatomy  of  the  ovary,  we  are  now  prepared  to  consider 
the  manner  in  which  the  follicles  and  their  contained  ova  are  formed. 
The  germ  e^jithelium,  which  forms  the  superficial  layer  of  the  fetal 
ovary,  undergoes  rapid  multiplication,  as  a  result  of  which  the  cells 
grow  in  a  direction  toward  the  vascular  stroma  of  the  ovary ;  this 
likewise  increases,  and  in  a  direction  toward  the  germ  epithelium. 
The  stroma,  developing  between  these  masses  of  cells,  which  are  off- 
shoots from  the  germ  epithelium^thus  isolates  them,  forming  islands 
or  nests.  These  nests  are  larger  below  than  above  where  they  are 
for  a  considerable  time  still  connected  with  the  superficial  germ  epi- 
thelium. Indeed,  at  birth  this  connection  exists  and  forms  what 
Pfliiger  has  denominated  the  ovarial  tubes.  The  cells  composing 
these  nests  multiply  themselves  by  the  process  of  karyokinesis,  thus 
increasing  the  size  of  the  nests,  and  forming  new  ones  by  being  con- 
stricted oif  from  the  old  ones.  Some  of  the  cells  of  the  germ  epi- 
thelium undergo  special  development  in  the  cell-body  and  nucleus, 


446  DISEASES  OF   WOMEN. 

and  become  ova,  wliicli  are  spoken  of  as  ])riinitive  ova.  Tlie  germi- 
nal vesicle  is  formed  before  tlie  vitellus  or  tlie  zona  pellucida ;  but 
whether  the  formation  of  the  germinal  spot  precedes  that  of  the 
gonninal  vesicle  has  not  been  fully  decided  in  the  vertebrates. 
KoUiker  finds  this  to  be  the  order  in  the  development  of  the  ova  of 
intestinal  worms.  As  the  multiplication  of  the  cells  of  the  germ 
epithelium  goes  on  as  already  described,  there  is  also  a  continually 
increasing  differentiation  of  these  cells  forming  the  primitive  ova. 
This  production  of  ova  takes  place  in  the  nests  as  well  as  in  the 
superficial  layer,  and,  as  a  result,  we  have  each  nest  containing  a 
number  of  ova,  and  ova  are  also  found  in  the  same  manner  in  the 
ovarian  tubes.  The  membrana  granulosa  is  fonned  of  the  cells  of 
the  nests  and  tubes  which  do  not  take  part  in  the  formation  of  the 
ova.  If  a  nest  or  an  ovarial  tube  contains  several  ova,  each  ovum 
will  form  a  center,  around  which  will  be  aggregated  a  layer  of  cells, 
forming  a  membrana  granulosa,  and  by  the  ingrowth  of  the  stroma 
between  these  collections  the  Graafian  follicles  are  formed.  External 
to  the  membrana  granulosa  is  formed  the  membrana  propria,  and 
still  more  externally  the  fibrous  capsule  or  theca  foUiculi.  As  already 
stated,  two  or  even  three  ova  may  become  envelo])ed  in  a  single 
layer  of  cells,  and  thus  a  single  Graafian  follicle  be  formed  contain- 
ing two  or  three  ova.  The  ova  and  the  membrana  granulosa  are 
consequently  formed  from  the  germ  epithelium,  which,  as  has  been 
seen,  consist  of  cells  from,  the  mesoblast.  The  membrana  propria, 
the  theca  folliculi,  the  stroma,  and  the  vessels  are  produced  from  the 
fetal  stroma,  which  was  also  originally  an  outgrowth  of  the  meso- 
blast. Some  excellent  authorities,  among  whom  may  be  mentioned 
Pfliiger  and  Kolliker,  believe  that  Graafian  follicles  and  ova  are  pro- 
duced after  birth  ;  others  equally  reliable,  as  Bischoff  and  Waldeyer, 
deny  this. 

Ovulation. ^ — The  function  of  the  ovaries  is  primary  in  the  process 
of  reproduction.  Their  physiological  activity  precedes  the  uterine 
functions,  and  continues,  as  a  rule,  until  the  menopause,  and  possibly 
after  it.  Hence  the  functions  of  the  other  sexual  organs  appear  to 
be  responsive  to  the  influence  of  the  ovaries. 

There  are,  however,  differences  of  opinion  concerning  this  matter. 
Observations  have  been  made  which  show  that  ovulation  and  men- 
struation occur  independently  of  each  other,  in  exceptional  cases  at 
least,  and  a  high  degree  of  importance  has  been  given  to  that  appar- 
ently independent  action ;  but  such  irregularities  are  the  exception, 
not  the  rule.  There  are  facts  in  abundance  to  prove  that,  when  the 
ovaries  are  absent  or  rudimentary  from  birth,  the  function  of  the 


DISEASES  OF  THE  OVARIES.  447 

litems  is  never  established,  and  the  removal  of  the  ovaries  after 
puberty  arrests  nieustruation  in  the  majority  of  cases.  All  that  we 
know  regarding  the  influence  of  the  ovaries  upon  development  of 
the  individual,  and  the  exercise  of  the  sexual  functions  tliroughout 
the  reproductive  period  of  life,  points  to  the  conclusion  that  these 
organs  are  the  prime  movers  and  controlling  agencies,  to  s])eak  fig- 
uratively, in  the  sexual  system.  The  simple  facts  that  ovulation  and 
menstruation  do  not  follow  each  other  in  consecutive  order  in  excep- 
tional cases,  and  that  the  two  functions  are  occasionally  performed 
independently  of  each  other,  do  not  affect  the  general  rule  in  physi- 
ology. Because  irregularities  occur  in  the  harmonious  action  of  the 
sexual  organs,  their  independence  need  not  be  doubted.  The  same 
natural  order  of  phenomena  is  observed  in  all  processes  of  tlie  human 
economy.  The  primary  action  of  an  organ  that  stands  at  the  head 
of  a  system  sets  all  the  subordinate  organs  in  functional  motion. 
Taking  food  is  the  first  step  in  the  great  process  of  nutrition,  and 
digestion  and  assimilation  follow  in  natural  physiological  order. 
There  are  occasional  irregularities  in  the  succession  of  the  processes 
of  nutrition,  as  when  gastric  juice  is  secreted  in  the  absence  of  food 
in  the  stomach  ;  but  such  events  are  exceptions  to  the  rule.  Certain 
impressions  made  upon  the  brain  are  followed  by  definite  mental 
phenomena,  but  the  brain  sometimes  fails  to  respond  to  impres- 
sions ;  and,  again,  it  occasionally  acts  independently  of  extrinsic 
excitants.  So,  also,  an  action  or  function  which  has  been  be- 
gun by  a  given  influence  may  continue  after  the  cause  which  pro- 
duced it  has  been  removed.  If  we  accept  the  idea  that  the  ovaries 
are  essential  to  the  very  existence  of  the  sexual  system,  and  that  their 
ofiice  is  the  highest  and  the  first  in  the  order  of  events  which  col- 
lectively make  the  complete  process  of  production,  it  is  easy  to  under- 
stand that  their  absence  would  arrest  the  action  of  the  whole  system. 
They  are  paramount,  not  subordinate,  in  reproduction,  and  in  the 
maintenance  of  the  relationship  between  the  general  and  the  sexual 
systems  the  ovaries  are  undoubtedly  the  most  potential  agents.  The 
uterus  and  vagina  are  superadded  structures,  rendered  necessary  by 
a  more  complex  and  perfect  sj^stem  of  reproduction  in  the  higher 
species.  The  anatomical  and  physiological  value  of  the  ovaries  as 
factors  in  the  reproductive  system  suggests  an  equal  distinction  in 
their  association  with  the  general  system,  and  in  their  influence  upon 
it.     This  correlation  has  been  variously  estimated  by  authors. 

Dr.  Henry  Maudsley,  in  his  book  entitled  "  Body  and  Mind," 
says :  "  The  organic  system  has  most  certainly  an  essential  part  in 
the  constitution  and  the  functions  of  the  mind.    In  the  great  mental 


4-48  DISEASES   OF   WOMEN. 

revolution,  caused  by  the  development  of  the  sexual  system  at  pu- 
berty, we  have  the  most  striking  example  of  tlm  intimate  and  essential 
sympathy  between  the  bi'ain  as  a  mental  organ  and  other  organs  of 
the  body.  The  change  of  character  at  this  ])eriod  is  not  l>y  any 
means  limited  to  the  appearance  of  the  sexual  feelings  and  their 
sympathetic  ideas,  but,  when  traced  to  its  ultimate  reach,  will  be 
found  to  extend  to  the  highest  feelings  of  mankind,  social,  moral, 
and  even  religious.  In  its  lowest  sphere,  as  a  mere  animal  instinct, 
it  is  clear  that  the  sexual  appetite  forces  the  most  selfish  person  out 
of  the  little  circle  of  self-feeling  into  a  wider  feeling  of  family 
sympathy  and  a  rudimentary  moral  feeling.  The  consequence  is 
that,  when  an  individual  is  sexually  mutilated  at  an  early  age,  he  is 
emasculated  morally  as  well  as  physically.  It  has  been  affirmed  by 
some  philosophers  that  there  is  no  essential  difference  between  tlie 
mind  of  a  woman  and  that  of  a  man  ;  and  that,  if  a  girl  were  sul> 
jected  to  the  same  education  as  a  boy,  she  would  resemble  him  in 
tastes,  feelings,  pursuits,  and  powers.  To  my  mind,  it  w'ould  not 
be  one  whit  more  absurd  to  affirm  that  the  antlers  of  the  stag,  the 
human  beard,  and  the  cock's  comb  are  the  effects  of  education,  or 
that,  by  putting  a  girl  to  the  same  education  as  a  boy,  the  female 
generative  organs  might  be  transformed  into  male  organs.  The 
physical  and  mental  differences  between  the  sexes  intimate  them- 
selves very  early  in  life,  and  declare  themselves  most  distinctly  at 
puberty ;  they  are  connected  with  the  influence  of  the  organs  of 
generation." 

This  much  being  claimed  by  so  high  an  authority  for  the  influ- 
ence of  the  sexual  organs  upon  the  development  and  function  of  the 
brain  and  nervous  system,  I  may  inquire  how  far  the  ovaries  are  re- 
sponsible for  such  results.  Virchow  and  others  have  stated  that  the 
ovaries  give  to  woman  all  her  characteristics  of  body  and  mind,  and 
I  accept  the  proposition  without  qualification,  feeling  sustained  in 
doing  so  by  the  fact  that,  when  the  ovaries  are  absent  or  defective 
from  birth,  the  characteristics  of  the  female  sex  are  never  fully  de- 
veloped. The  tendency  in  the  development  of  those  in  whom  the 
ovaries  are  congenitally  absent  is  toward  the  masculine  type  of  the 
race.  I  have  seen  two  such  cases,  decidedly  masculine  in  their  phys- 
ical and  mental  attributes,  and  there  are  many  others  recorded  in 
our  literature.  There  are  some  authors,  however,  who  appear  to 
stand  in  opposition  to  what  is  here  claimed.  In  Dr.  GoodelKs  pa])er 
presented  to  the  Pennsylvania  State  Society,  he  says,  that  ''  The 
physical  and  psychological  influence  of  the  ovaries  upon  woman  has 
been  greatly  overrated."     And  again  he  says,  "  In  the  i)opular  mind 


DISEASES  OF  THE   OVARIES.  449 

a  woman  without  ovaries  is  no  woman."  He  then  gives  his  own 
views  which  are  that,  "  beyond  the  induction  of  sterility  and  the 
probal)le  absence  of  menstruation,  the  deprivation  of  the  ovaries 
after  puberty  does  not  change  the  character  of  the  woman."  Bat- 
tey,  Hegar,  Wells,  and  Peaslee,  are  given  as  confirming  this  doc- 
trine. The  views  held  by  these  authors  are  based  upon  observations 
of  mature  women  from  whom  the  ovaries  have  been  removed.  This 
alone  is  not  a  trustworthy  source  of  information,  because  the  results 
obtained  up  to  the  present  time  appear  to  be  quite  variable.  For 
example,  Dr.  T.  G.  Thomas  had  one  patient  who  was  passive  in 
her  sexual  relations  before  her  ovaries  were  removed,  but  became 
aggressive  afterward.  On  the  other  hand,  Dr.  M.  A.  Fallen,  in  a 
paper  read  before  the  American  Medical  Association,  in  June  last, 
related  the  history  of  a  girl  who  was  promptly  and  completely 
cured  of  "  hystero-epilepsy "  and  an  incantrollable  desire  for  self- 
pollution  by  Battey's  operation. 

It  is  true,  no  doubt,  that  an  individual  who  has  been  fully  devel- 
oped under  the  influence  of  the  ovaries,  will  continue  to  manifest  her 
former  attributes  of  body  and  mind  after  these  organs  are  removed, 
but  it  does  not  therefore  follow  that  the  ovaries  were  negative  in  the 
])rocess  of  developing  and  maintaining  those  attributes.  One  who  has 
become  blind  in  middle  life  will  talk  familiarly  and  understandingly  of 
objects  impressed  upon  the  mind  through  the  sense  of  sight,  but  one 
born  blind  can  not  comprehend  the  beauties  of  a  landscape.  This 
abundantly  proves  that  mental  peculiarities  may  continue  after  the 
physical  influences  which  caused  them  have  been  removed.  Obser- 
vations made  from  the  opposite  standpoint  give  evidence  which 
leads  to  the  same  conclusions.  We  find  that,  if  tlie  ovaries  are  pres- 
ent in  a  given  individual,  she  will  manifest  the  physical  and  psy- 
chical peculiarities  of  womanhood,  although  all  the  other  sexual  or- 
gans may  be  absent.  Women,  well  developed  in  all  that  is  pecul- 
iar to  the  sex,  have  been  observed  in  whom  the  uterus  and  vagina 
were  defective,  but  I  have  neither  seen  nor  heard  of  any  such  per- 
fection of  organization  occurring  when  the  ovaries  were  absent. 
Ferhaps  the  strongest  argument  on  this  point  is  the  fact  that  other 
parts  of  the  general  system,  when  modified  by  the  influence  of  the 
ovaries,  are  rendered  capable  of  performing  the  major  functions  of 
the  uterus,  as  is  illustrated  in  a  very  striking  manner  by  \dcarious 
menstruation  and  abdominal  gestation. 

In  this  connection,  a  brief  reference  ma)'  be  made  to  the  influ- 
ence of  the  nervous  system  in  controlling  the  functions  of  reproduc- 
tion.   The  full  discussion  of  this  question  involves  problems  in  phys- 
30 


450  DISEASES   OF   WOMEN. 

iology  whic'li  have  not  been  solved,  and  are  therefore  beyond  the 
scope  of  tliis  work.  Whether  the  higlier  nerve-ceutei's  are  devel- 
oped to  serve  the  demands  of  the  nutritive  and  reproductive  or<;an- 
izations,  and  whether  the  location  of  the  nerve-centers  which  preside 
over  sexual  phenomena  is  in  the  cerebelhnn  or  the  lunibo-sacral 
portion  of  the  spinal  cord,  are  questions  which  I  am  not  at  present 
able  to  answer.  It  is  sufficient  for  the  present  purpose  to  keeji  in 
mind  that  the  sexual  organs  are  dependent  upon  the  general  nutri- 
tive system  for  organic  support,  and  that  they  stimulate,  depress,  or 
modify  nutrition  through  the  ganglionic  nerves  chiefly,  and  tliat  the 
portion  of  the  brain  which  presides  over  the  organic  functions  also 
dominates  the  reproductive  organs.  We  should  also  recognize  the 
fact  that  the  emotions  are  in  part  dependent  upon  the  sexual  organs 
for  their  development,  and  on  the  other  hand  that  the  sexual  organs 
are  largely  affected  by  the  emotions.  Metaphysicians  agree  in  stat- 
ing that  the  sexual  appetence,  which  owes  its  existence  almost  en- 
tirely to  the  ovaries,  leads  to  more  emotions  than  any  other  human 
tendency,  and  clinical  observations  afford  good  evidence  to  the  phy- 
sician, that  the  emotions  affect  the  functions  of  the  sexual  organs  in 
a  marked  degree.  Grief,  fear,  anger,  and  even  great  joy  are  capa- 
ble of  arresting  menstruation  and  probably  ovulation  also.  In  view 
of  this  great  potentiality  of  the  ovaries  in  developing  certain  ca])a- 
bilitics  of  the  brain  and  nervous  system  and  in  influencing  their 
functions,  it  is  evident  that,  in  order  to  maintain  harmonious  action 
of  the  whole  organization,  it  is  necessary  tliat  the  ovaries  shall  exist 
in  full  development  and  functional  activity.  On  the  other  hand, 
these  organs  which  are  essential  to  the  well-being  of  the  individual 
must,  when  diseased,  exercise  a  potent  influence  in  deranging  the 
brain  and  nervous  system. 

From  a  somewhat  extended  consideration  of  this  subject,  I  am 
satisfled  that  a  great  many  affections  of  the  brain  and  nervous  sys- 
tem are  due  to  disease  of  the  ovaries.  The  remote  effects  of  ovarian 
disease  have  been  observed  and  recorded  to  some  extent,  but  not  so 
fully,  I  presume,  as  they  might  be.  The  tendency  of  observers  has 
been  to  attribute  certain  mental  derangements  and  diseases  of  the 
nervous  system  to  the  sexual  organs  in  general-  or  the  uterus  espe- 
cially. A  little  attention  to  some  of  the  known  defects  and  diseases 
of  the  ovaries  and  their  relations  to  diseases  of  the  brain  and  nerv- 
ous system  w^ill,  I  think,  materially  change  that  phase  of  the  subject. 

Imperfect  development  of  the  ovaries  not  only  inodifles  the  phys- 
ical peculiarities  of  the  indi\4dual,  but  also  retards  the  development 
of  the  higher  nerve-centers.     The  demands  of  the  sexual  organs  (e&- 


DISEASES  OF  THE  OVARIES.  451 

pecially  tlio  ovaries)  stimulate  the  brain  to  a  higher  development. 
A  very  large  part  of  the  brain  and  nerve  power  is  devoted  to  repro- 
duction, and  if  that  function  is  never  estal)lished  because  of  the  ab- 
sence of  the  ovaries,  the  brain  and  nervous  system  are  never  fully 
developed.     When  a  woman  is  deprived  of  the  sexual  organs  the 
nutritive  system  may  possibly  attain  a  normal  development,  but  the 
nervous  system  does  not — it  remains  upon  a  lower  plane.     There  is 
usually  mental  weakness  and  often  derangement  of  mind  among 
those  in  whom  the  ovaries  are  imperfectly  developed.     Among  six- 
teen young  single  women,  that  came  under  my  observation  in  the 
Insane  Asylum,  I  found  twelve  who  had  imperfectly  developed  sex- 
ual organs.     Some  of  them  had  never  menstruated  at  all,  and  others 
had  done  so  imperfectly.     The  history  of  these  cases  led  to  the  con- 
clusion that  the  defective  development  of  the  ovaries  was  an  impor- 
tant element  in  causing  insanity.     They  no  doubt  inherited  an  in- 
sane neurosis  or   diathesis,  but  the   absence  of  ovarian  influence, 
which  favors  a  higher  and  more  complete  development  of  the  nerve- 
centers,  acted  as  the  major-cause  in  producing  the  insanity.     This  is 
not  claimed  to  be  a  positively  correct  deduction,  but  there  is  cer- 
tainly strong  presumptive  evidence  that  such  was  the  case.     The 
mental  derangement  appeared  in  the  majority  of  them  at  or  about 
the  period  of  puberty.     There  was  nothing  in  the  size  or  develop- 
ment of  these  patients  to  indicate  any  marked   defect  in  the  nutri- 
tive system.     The  nervous  and  sexual  system  alone  were  deficient. 
They  appeared  to  have  passed  through  girlhood  in  a  normal  way 
(although  not  manifesting  a  high  order  of  mental  capacity)  until 
the  period  when  the  sexual  organs  should   have  begun  to  exercise 
their  influence  in  completing  the  higher  development  of  the  nerve- 
centers.     When  that  failed  to  take  place,  the  brain  became  deranged, 
instead  of  assuming  new  activities.     Still  it  is  possible  that  the  im- 
perfectly  developed  sexual   organs  resulted  from  inferior  general 
organizations  which  were  from  the  beginning  of  a  low  type,  and 
that  the  insanity  which  followed  was  due  to  transmitted  lesions,  and 
was  not  dependent  upon  the  sexiial  organs  at  all.     However,  the 
facts  appear  to  favor  the  opposite  conclusion.     One  thing  is  certain 
regarding  this  subject :  there  is  enough  in  the  nature  of  the  cases 
mentioned  to  invite  further  investigation  in  order  to  settle,  as  far  as 
possible,  the  relation  of  the  ovaries  to  insanity  and  other  diseases  of 
the  nervous  system  which  occur  at  puberty. 

As  the  period  of  puberty  approaches  a  considerable  number  of 
Graafian  follicles  (from  twelve  to  thirty)  enlarge,  the  largest  reach- 
ing a  diameter  of  half  an  inch.     In  the  early  stage  of  development, 


452  DISEASES  OF  WOMEN. 

it  will  be  remem1)ored,  the  smallest  follicles  were  found  in  the  corti- 
cal layer,  those  of  medium  size  in  the  middle  layer,  and  still  deeper, 
the  larger  follicles.  These  follicles  increase  in  size  by  the  produc- 
tion of  an  increased  amount  of  liquor  folliculi.  This  so  distends  the 
wall  of  the  follicle  as  to  cause  it  to  project  from  the  surface  of  the 
ovary,  and  to  become  thinner  and  thinner  until  finally  it  bursts,  dis- 
charging the  ovum  with  some  of  the  cells  of  the  membrana  granu- 
losa, especiall}'  those  forming  the  cumulus  proligerus.  The  ovum 
passes  into  the  Fallopian  tube,  and  through  it  descends  to  the  uterus. 
This  ripening  and  discharge  of  ova  is  the  process  of  ovulation  and 
occurs  periodically,  in  the  human  female  about  every  four  weeks. 
As  the  time  approaches  in  each  month  for  the  rapture  of  a  follicle 
there  is  an  abundant  formation  of  vascular  loops  in  connection  with 
increased  growth  of  the  membrana  propria,  which  together  with 
the  liquor  folliculi  distends  the  wall  of  the  follicle.  This  distention 
stimulates  the  ovarian  nerves,  and  as  a  result  there  is  an  increased  flow 
of  blood  to  the  ovaries  and  other  organs  of  generation.  The  wall  of 
the  follicle,  in  addition  to  being  distended,  also  becomes  fatty  at  its 
most  projecting  part,  and  when  it  is  no  longer  able  to  withstand  the 
internal  pressm-e  it  bursts  and  the  ovum  is  discharged.  AVhen  this 
rupture  takes  place  there  is  in  the  human  female  haemorrhage  from 
the  vessels  already  spoken  of  as  being  found  in  the  interior  of  the 
follicle.  The  amount  of  blood  effused  is  sufficient  to  fill  the  cavity 
of  the  follicle.  It  soon  coagulates,  the  serum  is  reabsorbed,  the 
haemoglobin  becomes  h^ematoidin,  and  after  a  time  the  coloring-mat- 
ter disappears.  In  short,  the  same  changes,  take  place  in  the  blood 
here  as  when  a  haemorrhage  occurs  elsewhere  in  a  closed  cavity. 
The  wall  of  the  follicle  becomes  hypertrophied  and  convoluted,  and 
later  on  undergoes  fatty  degeneration,  with  the  formation  of  lutein, 
giving  to  the  structure  a  yellow  color,  on  which  account  it  has  been 
called  a  corpus  luteum.  The  corpus  luteum  spurium  by  which 
name  the  corpus  luteum  of  menstruation  is  known,  reaches  its  maxi- 
mum of  development  at  the  end  of  the  third  week  after  menstrua- 
tion, at  which  time  it  commences  to  diminish  in  size  until  at  the 
end  of  the  eighth  week  it  is  reduced  to  an  insignificant  yellowish 
cicatrix  about  one  fourth  of  an  inch  in  diameter,  but  it  sometimes 
may  be  discovered  if  carefully  sought  at  the  end  of  eight  months. 
If,  however,  the  ovum  which  escaped  from  a  given  Graafian  follicle 
becomes  impregnated,  then  the  process  becomes  modified  in  that  fol- 
licle. The  corpus  luteum  is  then  denominated  verum  instead  of 
spurium.  The  differences  between  the  two  varieties  of  coi'pora 
lutea  are  of  degree  not  of  kind.     The  changes  which  take  place  are 


DISEASES   OF  THE   OVARIES.  453 

the  same  in  both  up  to  the  end  of  the  tliird  week,  then,  instead  of 
diminishing,  the  corpus  hitenm  veruni  continues  to  grow  until  the 
end  of  the  fourth  montli  when  it  reaches  the  height  of  its  develojj- 
ment.  It  retains  this  nuixininni  until  the  beginning  of  the  seventh 
month  when  it  commences  to  diminish,  l)ut  may  sometimes  still  be 
discovered  nine  months  after  delivery.  The  history  of  the  corpus 
hiteum  is  admirably  described  by  Dalton  to  whose  work  on  human 
physiology  the  reader  is  referred  for  a  detailed  account  of  its  forma- 
tion, and  the  subsequent  changes  which  it  undergoes. 


LESIONS   OF   FORMATION   OF   THE   OVARIES. 

Both  ovaries  may  be  entirely  absent,  or,  j)erhaps,  it  would  be 
more  correct  to  say,  entirely  rudimentary,  or  one  ma}""  exist  alone,  or 
there  may  be  a  third  one  present.  When  a  single  ovary  is  absent 
the  condition  of  uterus  unicornis  usually  exists,  although  this  mal- 
formation of  the  uterus  is  not  necessarily  accompanied  by  an  absence 
of  either  ovary. 

The  absence  of  an  ovary  may  be  accounted  for  in  different  ways ; 
it  may  not  have  been  developed,  it  may  have  been  properly  formed, 
and  by  some  dislocation  of  the  uterus  have  had  its  circulation  and 
nutrition  so  interfered  "with  as  to  have  caused  it  to  shrivel  and  be- 
come absorbed,  or  it  may  have  become  attached  to  some  other  ab- 
dominal organ,  and  then  its  absence  be  only  apparent  and  not  real. 

Several  cases  are  on  record  in  which  a  third  ovary  has  been 
found.  The  most  interesting  of  these  is  one  which  is  described  and 
figured  by  Winckel  in  his  work  on  "  Diseases  of  Women."  In 
most  of  the  instances  the  supernumerary  ovary  was  found  near  one 
or  the  other  of  the  normal  ovaries,  and  either  behind  or  in  the  broad 
ligament.  In  Winckel's  case  it  was  situated  in  front  of  the  uterus 
and  connected  with  the  posterior  wall  of  the  bladder. 

As  Winckel  has  so  well  pointed  out,  these  cases  of  supernumer- 
ary ovaries  are  always  to  be  borne  in  mind  in  making  a  diagnosis. 
A  cyst  forming  in  the  third  ovary  as  found  in  his  case  might  be  de- 
tected between  the  bladder  and  the  utenas,  and  be  mistaken  for 
some  other  form  of  tumor.  In  such  cases  also  the  removal  of  two 
ov'aries  may  not  prevent  conception,  the  third  ovary  being  in  all  re- 
spects normal,  and  consequently  able  to  discharge  ova.  So  also  even 
after  two  ovaries  are  removed,  should  a  third  exist  a  cystoma  may 
form,  which  will  require  operative  interference. 


CHAPTER  XXY. 

DISEASES    OF   THE   OVARIES.      (CONTINUED.) 

HYPERiEMIA,    ACUTE    AND    CHRONIC    OVARITIS    AND     PRO- 
LAPSUS   OF  THE   OVARIES. 

Inflammation  of  the  Ovaries. — There  are  two  forms  of  inflamma- 
tion of  the  ovaries,  the  acute  and  the  chronic.  These  are  verv  dis- 
tinctly different  so  far  as  their  clinical  history  is  concerned.  There 
is  another  affection  closely  allied  to  these  which  is  described  by  some 
writers  as  hypememia.  All  these  are,  however,  but  different  degrees 
of  the  same  affection,  though  each  follows  a  different  course  and 
gives  a  history  peculiar  to  itseK.  This  latter  fact  justifies  the  con- 
sideration of  the  acute  and  chronic  forms,  at  least,  of  ovaritis  as  sepa- 
rate affections.  The  third  form,  hypei'oemia,  is  not  so  fully  under- 
stood nor  does  it  stand  out  so  distinctly  from  the  chronic  form  as  to 
make  its  description  easy. 

Ovarian  Hyperaemia. — While  many  of  the  characteristics  of  ova- 
rian hyperaemia  are  like  those  of  ovaritis,  there  is  very  good  reason 
based  upon  clinical  evidence,  to  believe  that  the  two  are  different 
both  in  pathology  and  clinical  history. 

Ovarian  hypenemia,  as  it  is  generally  observed,  resembles  many 
of  the  so-called  functional  diseases  of  the  ovary,  in  that  there  is  de- 
rangement of  function,  with  symptoms  of  oi'ganic  disease  which 
usually  disappear,  leaving  no  evidence  that  there  has  ever  been  any 
charge  of  stricture  or  any  products  of  inflammation.  All  this  dem- 
onstrates that  the  pathology  is,  as  the  name  imj^lies,  a  derangement 
of  circulation  in  which  there  is  congestion,  and  the  consequent  de- 
rangement of  function  M'ith  the  accomjianying  or  resulting  pain  and 
suffering.  The  hyperivmia  usually  affects  both  ovaries,  and,  as  a 
rule,  extends  to  the  other  pelvic  organs,  after  a  time,  at  least.  The 
derangement  of  function  also  extends  to  the  uterus  giving  rise  to 
derangement  of  menstruation.     In   fact,  the  congestion  and  func- 


DISEASES  OF  TDE   OVARIES.  455 

tional  derangements  of  the  uterus  are  secondary  to  the  ovarian 
liyperannia.  There  is  much  in  regard  to  ])athologj  of  this  affection 
wliich  is  inferred  from  the  symptoms,  and  can  not  be  demonstrated 
by  post-mortem  investigation.  The  congestion  may  be  of  long  or 
of  short  duration,  its  continuance  depending  upon  the  persistence 
of  the  causes  which  give  rise  to  it.  If  it  is  well-marked  and  long- 
continued,  it  tends  to  chronic  ovaritis,  and,  perhaps,  to  degeneration 
of  the  ovaries  and  premature  atrophy.  Should  the  causes  which  pro- 
duce the  congestion  continue  active  and  no  treatment  be  employed, 
the  affection  may  continue  indefinitely.  The  general  health  be- 
comes undermined  by  the  derangement  of  the  menstrual  function 
and  the  exhaustion  of  the  nervous  system ;  and  if  the  patient  is  not 
relieved  by  treatment  or  by  improved  hygienic  conditions,  she  con- 
tinues a  sufferer  until  the  menopause. 

With  so  little  that  is  definite  regarding  the  pathology,  one  might 
well  ask  if  the  fact  is  yet  established  that  there  is  a  distinct  affection 
to  be  known  as  ovarian  hypergeniia.  In  answer  to  this,  it  can  only 
be  said  that  the  clinical  history  clearly  points  to  this  derangement  of 
the  circulation  as  the  only  rational  explanation  of  the  i)heuomena 
presented  in  these  cases.  It  should  be  stated  here  that  there  neces- 
sarily must  be  present  in  this  affection  a  derangement  of  ovarian  in- 
nervation as  well  as  hypersemia.  In  fact,  it  appears  that  this  de- 
rangement is  the  starting-point  in  the  morbid  condition.  This 
view  of  the  matter  is  favored  by  the  affection  depending  for  its 
origin  upon  perversion  of  the  emotions  in  those  of  nervous  tempera- 
ment. 

Symptomatology. — Hypercemia  of  the  ovaries  occurs  most  fre- 
quently among  those  who  are  unmarried,  or  among  young  widows 
who  have  never  had  children. 

It  does  not  come  on  abruptly  like  an  attack  of  acute  ovaritis,  as 
a  rule,  though  it  occasionally  does  so,  but  is  developed  rather  gradu- 
ally. Those  most  liable  to  this  affection  are  the  nervous  and  emo- 
tional who  live  in  conditions  of  life  favoring  excitation  without 
complete  functional  action  of  the  sexual  organs.  I  have  never  seen 
a  case  of  this  kind  among  those  who  lived  under  wholesome  con- 
ditions of  life  or  who  were  married,  bearing  and  nursing  children, 
and  who  lived  quiet,  rational  lives.  At  the  beginning  there  are 
pain  and  heaviness  in  the  region  of  the  ovai'ies,  usually  accom- 
panied by  much  nervous  disturbance  of  the  nature  of  irritability  and 
weakness,  the  patient  being  easily  excited  and  as  easily  fatigued. 
Soon  after  the  appearance  of  these  symptoms  the  menstrual  func- 
tion becomes  deranged.     There  is   usually  monorrhagia,  which  is 


456  DISEASES  OF  WOMEN. 

preceded  by  increase  of  the  ovanan  jiain.  Sometimes  the  pain  is 
relieved  and  tiie  patient  feels  niucli  better  during  the  nienstmal 
riow,  and  for  a  time  after  it  ceases.  In  some  cases  the  first  synij) 
torn  developed  is  derangement  of  the  menstrual  functicjn,  gener- 
ally too  frequent,  and  too  free  menstruation.  In  a  word,  menorrhagia 
is  the  most  prominent  symptom  of  ovarian  hyperaemia.  The  free 
flow  being  due  originally  to  the  ovarian  excitation  is  conservative 
at  first,  I  believe,  relieving  the  congestion  which  j)roduced  it.  I 
have  frequently  seen  young  women,  who  apparently  suflFered  from 
ovarian  congestion,  recover  completely  after  one  or  more  free  at- 
tacks of  menorrhagia.  When  the  excessive  menstruation  does  not 
reheve  the  congestion,  which  it  certainly  will  not  do  if  the  causes 
which  produced  it  are  continued,  then  it  leads  to  antemia  and  neu- 
rasthenia, and  this  state  of  health  may  continue  indefinitely. 

There  are  other  symptoms  which  may  be  mentioned,  as  backache 
and  general  pelvic  tenesmus,  increased  on  walking  sometimes,  but 
not  always.  In  the  less  severe  forms  of  hyjjeraemia  of  not  very 
long  standing,  active  muscular  exercise  gives  relief  not  for  the  time 
only,  but  is  oftentimes  permanently  beneficial.  There  is  often  irri- 
tability of  the  bladder,  which  is  purely  nervous. 

Physical  Signs. — There  is  tenderness  on  deep  pressure  made  in 
the  iliac  regions,  not  acute,  but  of  that  dull  character  which  is  pecul- 
iar to  the  ovaries.  As  the  disease  affects  both  ovaries,  as  a  rule, 
there  is  tenderness  alike  on  both  sides. 

Bimanual  examination  usually  shows  tenderness  better  than  ab- 
dominal pressure,  but  I  have  found  that  iu  these  cases  it  is  very  diffi- 
cult to  grasp  the  ovaries  between  the  two  hands,  owing  to  the  fact 
that  the  abdominal  muscles  are  tense  ;  while  in  the  majority  of  cases 
there  is  tenderness  if  pressure  is  made  upon  the  ovaries,  either 
through  the  vaginal  or  abdominal  walls,  I  have  seen  many  cases  in 
which  steady  but  not  too  heavy  pressure  in  the  iliac  regions  gave  re- 
lief. Perhaps  these  were  cases  of  the  kind  that  Charcot  calls  hys- 
tero-epilepsy,  in  which  the  convulsions  are  relieved  by  pressure  upon 
the  ovaries.  I  have  seen  some  of  Charcot's  cases,  and  believe  them 
to  be  ovarian  hyperaemia. 

The  physical  signs  obtained  are  rather  negative,  but  by  excluding 
the  evidence  of  other  ovarian  affections,  and  takhig  the  history  into 
account  a  presumptive  diagnosis  can  be  made,  and  the  diagnosis  will 
be  confirmed  by  the  subsequent  history.  Under  treatment  and  im- 
proved moral  and  physical  hygiene,  recovery  will  take  place  much 
more  promptly  and  completely  than  in  chronic  inflammation. 

In  connection  with  this  affection  of  the  ovaries,  especially  if  it 


DISEASES   OF   THE   OVARIES.  457 

has  existed  for  several  months,  there  is  usually  congestion  of  the 
uterus  and  vagina  which  yields  promptly  to  treatment. 

Prognosis. — The  great  majority  of  patients  recover  under  appro- 
priate treatment.  In  fact,  many  of  them  recover  after  the  causes 
are  removed  without  any  treatment  whatever.  This  will  be  seen  in 
the  history  of  the  cases  given  further  on. 

Causation. — Overstimulation  of  the  emotions  in  tliose  of  a  nerv- 
ous temperament  is  one  of  the  chief  causes  of  ovarian  congestion. 
This  is  operative  among  those  who  are  not  usefully  employed,  but 
are  permitted  or  even  encouraged  to  turn  their  attention  to  the 
procreative  function  while  they  are  still  undergoing  development. 
Stimulating  tonics  which  create  an  appetite  which  is  not  satisfied 
with  food  will  cause  gastric  congestion,  and  all  the  consequences 
which  arise  therefrom.  In  like  manner  stimulating  tbe  sexual 
appetence  of  unoccupied  emotional  young  girls  by  evil  influ- 
ences or  improper  associations  leads  to  ovarian  congestion.  Those 
who  have  lived  in  the  proper  exercise  of  the  sexual  function,  but 
have  been  abruptly  cut  off  from  normal  gratification,  are  prone  to 
ovarian  congestion.  Indulgence  beyond  normal  gratification  is  also 
said  to  have  produced  the  same  result.  All  these  causes  are,  to  a 
great  extent,  psychical,  but  ovarian  congestion  may  be  produced  by 
purely  physical  causes.  It  may  be  secondary  to  endometritis,  seden- 
tary habits,  and  constipation,  which  may  interrupt  the  free  circula- 
tion in  the  pelvic  organs. 

It  is  rare,  however,  that  cases  of  ovarian  congestion  can  be  traced 
to  such  causes. 

Treatment. — The  removal  of  the  cause,  when  that  can  be  accom- 
plished, is,  as  I  have  already  said,  often  sufficient  to  give  relief. 
The  termination  of  an  engagement  in  marriage  has  cured  the  men- 
orrhagia  in  many  cases,  and  complete  recovery  has  followed  when 
pregnancy  occurred. 

A  like  good  has  been  brought  about  in  younger  patients  by  di- 
recting the  attention  to  something  other  than  self  and  the  feelings 
and  emotions.  A  change  from  books  and  society  to  the  woods  and 
fields,  and  out-door  occupation  in  the  way  of  amusements  should  be 
employed.  Bathing  is  useful — either  sea-bathing  or  the  shower-bath 
— if  the  patient  is  strong  enough  to  bear  it.  Tonics  to  restore  the 
general  strength,  nux-vomica  being  the  most  efiicient;  counter- 
irritants,  ergot  and  bromides  complete  the  list  of  therapeutic  agents. 

The  tonic  and  ergot  should  be  given  through  the  day,  and  the 
bromide  at  night  to  seciu-e  rest  and  sleep. 

Acute  Ovaritis. — This  is  quite  distinct  from  other  ovarian  affec- 


458  DISEASES  OF   WOMEN. 

tioTis,  because  it  is  probably  always  tlie  result  of  some  special  cause 
— usually  a  specitic  poison,  such  an  gonorrlKx-al  infection,  ])uc'rperal 
septicaemia,  or  some  constitutional  condition  like  that  wliieli  exists 
in  the  erni)tive  fevers  and  in  acute  rheumatism.  It  may  also  be 
traumatic,  though  that  is  rare,  except  when  the  ovaries  become  in- 
volved in  a  general  pelvic  inflammation  due  to  an  injury.  There 
has  been  and  still  is  much  confusion  of  tlioui^dit  regarding  the  pa- 
thology of  ovaritis.  Some  of  the  contiicting  accounts  arise,  I 
presume,  from  confounding  acute  and  chronic  ovaritis  and  ovarian 
hypera?mia.%  There  is,  no  doubt,  so  marked  a  resemblance  between 
these  three  affections,  and  they  are  so  often  associated  that  it  Ls  im- 
possible to  differentiate  them  in  many  instances.  Still,  between  the 
typical  causes  of  each,  met  occasionally  in  practice,  the  distinction 
can  be  easily  made.  The  acute  affection  runs  its  course  rapidly,  and 
terminates  either  in  death  or  a  subsidence  of  the  acute  inHaminatory 
symptoms  and  a  damaged  state  of  the  ovaries.  There  are  well-defined 
symptomatic  forms,  and  the  changes  of  stmcture  which  result  in 
connection  with  the  clinical  history  are  such  as  belong  to  acute 
inflammatory  action.  In  chronic  ovaritis  there  are,  on  the  con- 
trary, changes  which  take  place  much  more  slowly,  and  are  not 
marked  by  the  same  definite  products  of  inflammation.  In  conges- 
tion of  the  ovaries  there  are  no  tissue  changes.  It  appears  to  me 
that  acute  and  chronic  ovaritis  are  as  well  deflned,  both  in  clinical 
history  and  anatomical  changes,  as  acute  and  chronic  nephritis. 
There  is  still  much  need  of  more  observation  and  careful  comparisons 
of  the  clinical  history  and  post-mortem  aj^peai'ances  in  order  to  settle 
more  definitely  the  pathology  of  acute  ovaritis. 

Paiholocfy. — When  ovaritis  occurs  in  connection  with  the  puer- 
peral state,  only  one  ovary  is  affected  as  a  rule,  AD  the  tissues  of 
the  ovary  take  part  in  the  congestion,  which  is  the  first  morbid 
change  produced.  Following  the  congestion  there  is  swelling  from 
the  transudation  of  serum,  which  is  often  of  a  reddish  color.  The 
inflammation  involves  all  the  tissues ;  the  vesicles,  stroma,  parenchy- 
ma, and  the  envelope,  and  not  infrequently  the  fimbriated  extremity 
of  the  Fallopian  tube  is  involved,  and  the  peritonjieura  around  the 
ovary.  Then  the  ovary  becomes  surrounded  with  the  exudate,  so 
that  from  the  gross  appearances  it  is  not  possible  to  tell  whether  the 
ovary  or  the  peritonfeum  was  first  attacked.  The  changes  in  the 
ovar^"  are,  in  addition  to  general  serous  effusion,  destiniction  of  the 
vesicles  from  effusion  or  purulent  infiltration ;  sometimes  one  large 
abscess  is  formed  in  the  ovary  which  destroys  most  of  the  tissues ; 
in  other  cases  a  number  of  small  abscesses  are  found.     In  short. 


DISEASES  OF  THE  OVARIES.  4:59 

acute  ovaritis  is  general  as  a  rule,  but  occasionally  partial  ovaritis 
occurs.  From  what  has  been  said,  it  will  aj^pear  that  ovarian  intiani- 
iiiation  is,  in  its  morbid  anatomy,  simihir  to  adenitis  generally.  The 
congestion,  serous  effusion,  suppuration,  the  formation  of  single  or 
multiple  abscess,  and  plastic  exudations  on  the  free  surface  of  the 
ovary  are  the  usual  changes.  These  changes  are  manifested  in  dif- 
ferent degrees  at  various  parts  of  the  ovary,  due  in  part  to  the  course 
which  the  disease  follows,  but  more  especially  to  the  different  stract- 
ures  or  elements  which  compose  the  ovary.  In  addition  to  these 
pathological  changes,  there  are  others  which  may  or  may  not  occur. 
There  are  prolapsus  of  the  ovary  and  adhesions  to  neighboring  organs. 
The  abscess  may  open  into  the  rectum  or  the  peritoneal  cavity,  or 
find,  its  way  into  the  lymphatics  or  veins,  w^hich  are  often  dilated ; 
quite  frequently  the  abscess  does  not  discharge  at  all,  but  remains 
encysted. 

Symptomatology. — There  are  both  local  and.  constitutional  symp- 
toms in  acute  ovaritis.  There  may  be  a  chill  or  rigor,  followed  by 
fever,  nausea,  vomiting,  and  pain  more  or  less  acute.  The  acuteness 
of  the  pain  appears  to  be  greatest  when  the  peritonseum  is  affectedo 
There  is  marked  disturbance  of  the  nervous  system,  shown  by  irri- 
tability and  anxiety,  but  no  delirium ;  not  infrequently,  however, 
hysteria  and,  in  a  few  cases,  mania  have  been  developed. 

The  only  difference  which  I  have  noticed  between  the  symp- 
tomatic form  of  ovaritis  and  other  acute  pelvic  inflammation  is  that 
in  the  former  the  nervous  symptoms  are  more  marked.  In  mild 
forms  of  this  affection  the  constitutional  disturbances  are  less  severe ; 
still  there  is  an  elevation  in  the  temperature,  increased  frequency 
of  the  pulse,  and  deranged  primary  nutrition.  The  appetite  is  poor, 
and  there  are  dyspepsia,  flatulence,  and  constipation.  The  symp- 
tomatic form  subsides  to  some  extent  after  the  first  few  days,  and 
the  formation  of  pus  reawakens  the  general  disturbances.  There 
may  be  a  chiU,  followed  by  perspiration,  or  irregular  rigors  may 
occur,  and  the  pain  may  return  more  acutely.  The  local  sjTnptom 
is  pain,  w^iich  is  often  circumscribed,  the  patient  being  able  to  point 
out  the  exact  spot  in  the  iliac  fossa  where  the  pain  starts,  and  from 
which  it  radiates,  and  where  the  tenderness  is  felt  on  pressure.  There 
are  pelvic  tenesmus,  and  a  frequent  desire  to  urinate,  and,  if  the  left 
ovary  is  the  one  affected,  there  is  often  excruciating  pain  during 
defecation. 

Physical  Signs. — There  is  acute  tenderness  on  pressui-e,  more 
definitely  located  than  in  pelvic  peritonitis.  Sometimes  the  ovary 
can  be  felt  through  the  abdominal  walls.    This  is  frequently  the  case 


460  DISEASES   OF   WOMEN. 

when  the  ovary  is  fjreatly  eiilarojed  by  the  products  of  the  infhuu- 
mation,  and  is  tixed  high  up  by  adhesions.  By  the  vaginal  touch 
heat  and  tenderness  are  detected,  and  the  size  of  the  intlanied  ovary 
can  be  ascertained.  By  very  gentle  manipulation  the  uterus  and  the 
ovary  also,  perhaps,  are  found  to  be  movable  to  a  limited  degree. 
The  location  of  the  tumor,  its  partial  mobility,  its  form,  and  that  it 
is  not  connected  directly  to  the  uterus  all  go  to  aid  in  making  the 
diagnosis.  Sometimes  the  ovary  can  not  be  easily  felt ;  then  the 
rectal  touch  w^ill  enable  the  examiner  to  locate  it.  The  bimanual 
examination  Avill  also  be  of  very  matenal  assistance  in  forming  a  cor- 
rect opinion. 

Differentiation. — Owing  to  the  fact  that,  in  the  present  state  of 
science  regarding  this  affection,  the  diagnosis  is  not  at  all  times  easy 
to  make,  it  is  necessary  to  mention  the  conditions  which  resemble  it, 
and  point  out  the  differences  which  help  to  define  and  distinguish 
acute  ovaritis  from  them.  Acute  ovaritis  is  easily  distinguislied 
from  chronic  ovaritis  and  hyperaemia  by  the  absence  in  the  latter 
of  symptomatic  fever.  Much  aid  is  obtained  by  the  history  which 
nearly  always  presents  some  of  the  causes  which  give  rise  to  acute 
ovaritis. 

It  may  be  distinguished  from  pelvic  peritonitis  and  cellulitis  by 
the  physical  signs.  The  fixation  of  the  uterus  and  the  more  diffuse 
distribution  of  the  inflammatory  products  being  most  marked  in  the 
cellular  and  peritoneal  inflammation.  In  cases  of  acute  ovaritis  that 
are  complicated  with  cellulitis  or  peritonitis,  the  differential  diag- 
nosis can  not  be  made  upon  the  living  subject.  That  these  affections 
have  occurred  together  can  be  determined,  but  which  was  the  ]3ri- 
mary  affection  can  only  be  surmised  from  the  history. 

Progno-ns. — When  suppuration  occurs,  and  the  abscess  opens 
into  the  peritoneal  cavity,  a  fatal  termination  should  be  expected. 
Death  may  also  occur  from  septicaemia  when  the  contents  of  the  sac 
of  the  abscess  find  their  way  into  the  lymphatics  or  veins.  This, 
I  believe,  is  more  likely  to  occur  when  there  are  a  number  of  small 
abscesses  with  thin  walls.  If  the  accumulated  pus  is  discharged 
through  the  rectum  or  vagina,  or  if  the  abscess  becomes  encysted, 
recovery  may  take  place.  The  ovary  is,  of  course,  damaged  or  de- 
stroyed, but,  if  one  ovary  is  left  in  a  normal  state,  the  patient  may 
regain  health  and  bear  children.  In  some  cases  of  chronic  suppura- 
tion, in  cases  where  the  pus  is  discharged  through  the  rectum  or 
vagina,  or  is  walled  in  by  peritoneal  adhesions  from  plastic  exuda- 
tion, relief  may  be  obtained  by  surgical  means  to  be  referred  to 
when  discussing  the  treatment. 


DISEASES   OF  THE   OVARIES.  461 

Causation. — Tlie  causes  of  acute  ovaritis  iiave  already  been 
named. 

Puerperal  septic  absorption  and  gonorrhojal  infection  are  the 
chief  causes.  Lawson  Tait  has  called  attention  to  the  eruptive  fevers 
and  acute  rheumatism  as  giving  rise  to  acute  ovaritis,  and  my  own 
observations  agree  with  his  in  the  main. 

While  I  have  not  seen  ovaritis  occurring  in  connection  with  rheu- 
matism, I  have  seen  several  cases  caused  apparently  by  the  eruptive 
fevers.  I  have  never  seen  ovai'itis  due  to  traumatic  causes,  still  I 
can  believe  that  such  might  be  the  case. 

Treatment. — In  regard  to  the  management  of  acute  ovaritis,  I 
may  say,  in  brief,  that  the  cases  that  have  come  under  my  care  have 
been  treated  exactly  as  I  have  treated  pelvic  peritonitis  or  cellulitis. 
I  have  not  discovered  any  special  line  of  management  as  specific 
medication  ;  hence,  to  avoid  useless  repetition,  I  must  refer  the  reader 
to  the  treatment  of  the  above-named  affections.  1  may  remark  in 
passing  that,  knowing  that  the  causes  are  specific  in  the  majority  of 
cases,  care  may  be  taken  to  prevent  the  occurrence  of  ovaritis  by 
judicious  treatment  of  the  affections  which  give  rise  to  it.  There 
is  room  for  doubt,  however,  if  much  can  be  accomplished  in  this 
way. 

Chronic  Ovaritis. — This  form  of  inflammation  is  characterized  by 
the  slow  progress  of  the  affection.  It  does  not  come  on  abruptly 
hke  an  acute  attack,  but  more  gradually,  and  the  morbid  changes  of 
structure  resulting  from  this  process  are  also  developed  gi-adually. 
While  hypersemia  of  the  ovaries  and  acute  ovaritis  may  terminate  in 
chronic  ovaritis,  and  in  that  way  the  beginning  of  the  affection  may 
be  acute  and  rather  sudden  in  its  onset,  yet  that  is  exceptional.  Judg- 
ing from  the  cases  which  have  come  under  my  own  observation,  it  ap- 
pears that  the  affection  is  subacute  from  the  beginning,  and  has  a 
clinical  history  more  like  the  chronic  inflammations  and  degenera- 
tions of  other  glandular  organs,  as  for  instance  the  liver  and  kidneys. 

Pathology. ^-Th&  gross  appearance  of  the  ovaries  which  I  have 
seen  affected  with  chronic  ovaritis  varies  considerably,  the  variations 
being  due  perhaps  to  the  portion  of  the  structure  involved,  or  the 
stage  of  the  affection  at  which  the  examination  was  made.  Three 
rather  distinct  general  appearances  have  been  noticed.  In  one  the 
ovary  is  not  very  much  enlarged,  but  is  matted  in  appearance  as  if 
irregularly  hypersemic,  and  the  surface  is  quite  uneven  from  en- 
largement of  a  number  of  cysts.  On  section  it  is  found  that  many 
of  the  cysts  are  enlarged  or  overdistended  and  their  contents  differ 
in  color,  some  being  clear  or  normal,  some  dark  as  if  filled  with 


402  DISEASES   OF   WOMEN. 

bloody  senim,  and  others  of  a  dark-grayish  color,  more  like  the  con- 
tents of  a  small  abscess.  In  other  ciuses  the  ovary  is  enlarged  to 
nearly  double  its  normal  size,  and  is  soft  and  appears  oedematous. 
The  surface  is  as  smooth  as  normal,  but  here  and  there  distended 
follicles  are  seen  and  patches  which  might  be  either  imperfect 
scars,  or  scars  after  rupture  of  a  follicle  in  which  there  have 
been  minute  ti-ansudatiuns  of  blood.  In  the  third  form  the  ovary 
is  smaller  than  normal,  and  is  irregular  on  the  surface  and  alto- 
gether indurated.  The  diminution  appears  to  be  the  result  of  a 
scirrhosis.  In  either  of  the  three  conditions  the  peritonaeum  around 
the  ovary  may  be  thickened,  and  exuded  lymph  may  l>e  found  on  the 
surface  of  the  ovary  and  the  fimbriated  extremity  of  the  tube. 
When  such  exudates  are  found  there  is  generally  a  history  of  an 
acute  attack  which  took  place  in  the  early  part  of  the  ati'ection. 
This  also  leads  me  to  believe  that  mixed  cases  are  not  uncommon, 
that  is,  cases  of  chronic  ovaritis  with  circumscribed  pelvic  peritonitis, 
the  peritonitis  preceding  or  being  intercurrent  in  the  progress  of 
the  ovaritis. 

The  pathological  changes  in  the  histological  structures  of  the 
ovaries  have  led  to  the  conclusion  that  there  are  two  forms  of  chronic 
inflammation  of  the  ovaries,  the  division  being  based  upon  the 
structures  first  affected.  Slavjonsky  states  that  there  are  two  prin- 
cipal forms,  the  parencliymatous  and  the  interstitial.  In  the  paren- 
chymatous form  tlie  gland  tissue  is  the  site  of  the  inflan)matory 
action.  The  gross  appearance  of  the  ovary  corresponds  to  that  form 
first  described  above.  The  ovary  is  not  enlarged  at  first,  microscop- 
ical examination  shows  hypersemia  and  destruction  of  the  blood- 
vessels around  the  follicles.  The  liquor  folliculi  is  usually  turbid 
and  at  times  appears  purulent.  The  young  and  imperfoctly  devel- 
oped follicles  are  first  attacked  as  a  rule ;  and  their  ei)ithelial  cells 
are  changed,  becoming  in  some  binucleated,  in  others  undergoing 
granular  degeneration.  In  the  more  marked  inflammation  of  these 
immature  follicles  germinal  vesicles  can  not  be  found.  The  inflam- 
mation appears  to  begin  at  a  given  point  in  the  gland  tissue,  but  as 
the  process  continues  the  other  follicles  are  involved,  and  finally  the 
tissues  around  the  follicles  become  congested  and  thickened  from 
hyperplasia  of  its  elements. 

Interstitial  inflammation  begins  in  the  stroma  of  the  ovary. 
This  form  of  ovaritis  causes  the  large  ovary  already  mentioned. 
The  tissues  are  soft  and  oedematous  from  the  ti-ansudation  of  serum 
which  becomes  turbid.  The  blood-vessels  are  distended  showing 
hypersemia  which  must  have  existed  a  long  time.     In  addition  to 


DISEASES  OF  THE   OVARIES.  463 

the  oedema  and  congestion,  and  following  in  tlie  order  of  develop- 
ment of  the  products  of  the  inflammation,  the  connective-tissue  cells 
are  increased  in  number  and  diminished  in  size,  and  a  number  of 
cells  like  white  blood-corpuscles  and  occasionally  pus  are  seen,  the 
latter  in  small  quantit}'  and  irregularly  distributed.  I  am  indebted 
to  my  colleague  Prof.  Frank  Ferguson,  for  these  microscopical  ap- 
pearances and  the  pathology  here  given,  obtained  by  the  examina- 
tion of  inflamed  ovaries  which  I  have  removed. 

It  appears  that  no  matter  what  part  of  the  ovary  becomes  affected 
first  the  inflammation  will  in  time  extend  to  the  rest  of  the  organ, 
so  that  interstitial  and  parenchymatous  ovaritis  coexists  in  cases  of 
long  standing. 

The  final  result  of  the  inflammation  is  to  cause  partial  or  com- 
plete change  of  the  tissues  of  the  ovary.  The  condition  described 
as  atrophy  of  the  ovary  is  in  many  cases  the  result  of  chronic  in- 
flammation. 

Sym,j)tomatology. — The  history  of  chronic  ovaritis  includes  both 
local  and  constitutional  symptoms.  The  constitutional  derange- 
ments are  not  acute,  but  are  usually  marked  by  depression  of  the 
nutritive  and  nervous  system.  The  reflex  derangement  of  the  di- 
gestive organs  is  manifested  by  capricious  appetite,  nausea,  and 
sometimes  gastralgia.  The  bowels  are  usually  constipated  and 
tympanitic.  There  is  usually  nervous  debility  attended  with  great 
emotional  disturbance.  I  believe  that  I  have  seen  more  marked  de- 
rangement of  the  brain  and  nervous  system  caused  by  chronic  ova- 
ritis than  by  the  reflex  influence  of  any  other  affection  of  the  sexual 
organs.  These  constitutional  symptoms  are  progressive,  the  patient's 
general  health  becoming  more  impaired  month  after  month  as  the 
disease  advances.  The  local  manifestations  are  pain  and  derange- 
ment of  menstruation.  There  is  often  menorrhagia,  in  fact  that  is 
the  rule  but  in  cases  of  long  standing  I  have  seen  amenorrhoea.  The 
ovarian  pain  is  usually  increased  for  several  days  before  menstrua- 
tion, and  is  relieved  to  some  extent  when  the  flow  has  lasted  a  day 
or  two.  The  menstrual  pain  is  much  more  severe  and  persistent  if 
there  is  a  uterine  disease  accompanying  that  of  the  ovaries.  The 
ovarian  pain  varies  according  to  the  ovarian  tissue  affected.  When 
the  stroma  alone  is  the  site  of  the  disease  the  pain  is  less  severe. 
Much  more  suffering  is  experienced  when  there  is  circumscribed 
peritonitis  or  salpingitis. 

All  these  symptoms  are  aggravated  by  standing,  walking,  riding, 
or  sitting  in  a  stooping  position  for  any  great  length  of  time.  Most 
comfort  is  obtained  by  the  recumbent  position.     Sexual  excitation 


4GJ:  DISEASES  OF   WOMEN. 

and  coitus  cause  so  niueli  suffering  that  tlic  patient  shrinks  from 
both.     There  are  exee])ti(jus  to  this,  but  not  many. 

Physloal  Signs. — The  ovaries  are  tender  to  tlie  touch  and  the 
pain  excited  by  ])ressure  lasts  for  a  long  time  as  a  rule.  The  char- 
acter of  the  })ain  excited  by  the  touch  is  ovarian  in  character. 
When  the  ovary  is  enlarged  or  changed  in  form  it  can  sometimes  be 
nuide  out  by  the  bimanual  toucli.  The  ovary  is  usually  moval)le, 
and  its  separation  from  the  uterus  can  be  distinguished.  It  will  be 
observed  that  the  symptoms  and  physical  signs  of  chronic  ovaritis 
closely  resemble  those  mentioned  as  occurring  in  ovarian  hyjier- 
aimia.  The  fact  is  that  the  two  affections  have  many  features  in 
common,  Ilyperoemia  being  a  part  or  the  initial  stage  of  inflamma- 
tion the  manifestations  of  the  two  affections  are  alike. 

Between  ovaritis  and  ovarian  neuralgia  there  is  a  close  resem- 
blance, but  the  differences  are  also  equally  marked.  In  neuralgia 
there  is  no  evidence  of  inflammation,  it  is  not  continuous,  and  very 
often  the  ovary  is  not  tender. 

The  diagnosis  can  only  be  made  by  a  due  consideration  of  the 
history  as  related  to  the  cause,  duration,  physical  signs,  symptoms 
and  progress  of  the  affection. 

Prognosis. — If  the  patient  has  the  good  fortune  to  be  placed 
early  under  treatment,  the  chances  of  recovery  are  favorable.  This 
is  still  more  certain  if  only  one  ovary  is  affected.  The  disease  may 
go  on  in  one  ovary  to  complete  destruction  of  the  organ  by  hyper- 
plasia of  its  cellular  tissue  and  atrophy  of  its  glandular  elements, 
and  after  this  premature  atrophy  all  suffering  may  subside  except 
occasional  neuralgic  pain  :  and  the  other  ovary  may  perform  the 
ovarian  function.  In  case  the  disease  is  complicated  with  in- 
flammation of  the  neighboring  pcritonoBum,  and  there  is  marked 
destruction  of  tissue  from  the  inflammation,  and  suppuration  takes 
place,  relief  can  only  be  given  by  removing  the  ovaries.  There  is 
not  a  great  mortality  from  this  affection  :  I  have  never  seen  a  fatal 
case,  but  I  have  seen  several  in  which  life  was  not  worth  living. 

Causation. — Ovaries  that  are  not  fully  develojied  are  ]iredisposcd 
to  chronic  inflammation.  I  risk  making  this  statement  for  three  rea- 
sons :  1.  In  the  cases  that  have  come  under  my  care  there  has  been 
evidence  of  imperfect  develojiment  of  the  sexual  organs  shown  by 
the  general  state  of  the  patients.  Perhaps  it  would  be  more  correct 
to  say  an  arrest  of  growth  rather  than  an  arrest  of  development. 
2.  Pathological  investigation  shows  that  the  young  and  immature 
follicles  are  first  affected.  3.  Because  the  general  law  is  that,  in 
all  cases  of  imperfection  of  development  and  growth,  there  is  a  pre- 


DISEASES  OF  THE   OVARIES.  4G5 

disposition  to  disease.  In  such  organizations  the  chronic  ovaritis 
may  come  from  any  of  the  causes  which  produce  ovarian  hypersemia, 
and  which  have  ah-eady  been  enumerated.  Imperfect  invokition  of 
the  sexual  organs  following  parturition,  either  premature  or  at  term, 
is  no  doubt  the  starting-point  of  chronic  ovaritis.  This  is  to  be  jDre- 
sumed  from  the  fact  that  some  cases  can  be  traced  to  a  preceding 
confinement  or  miscarriage.  Long-continued  endometritis  may  cause 
chronic  ovaritis.  This  has  been  claimed  on  the  theoretical  ground 
of  anatomical  resemblance  or  identity  of  the  endometrium  and  the 
glandular  stmcture  of  the  ovaries.  This  in  itself  would  not  be  suf- 
ficient reason  for  such  an  opinion,  because  we  know  that  extension 
of  the  inflammatory  process  from  one  organ  to  another  is  not  influ- 
enced by  similarity  of  tissue.  But  the  fact  is  correct,  apparently, 
though  the  theory  explaining  it  may  be  fallacious.  I  have  carefully 
recorded  the  history  of  a  number  of  cases  in  which  there  existed 
endometritis  first,  and  then  chronic  ovaritis  appeared.  It  is  possible, 
also,  that  the  causes  which  give  rise  to  acute  ovaritis  might,  under 
certain  circumstances,  give  rise  to  the  chronic  form.  Of  this  I  have 
no  personal  knowledge. 

Treatment. — Every  means  should  be  employed  to  improve  the 
general  health  of  the  patient,  and  relieve,  as  far  as  possible,  the  local 
pain  and  general  nervous  excitement.  Tonics,  generous  diet,  and  open 
air — when  the  patient  can  be  taken  out — and  bromides  to  quiet  ex- 
citement. When  the  bromides  are  required  for  too  long  a  time, 
other  remedies  may  be  used,  such  as  lupulin,  camphor,  valerian,  or 
cannabis  Indica.  Counter-irritation  by  blisters,  iodine,  and  the  actual 
cautery  often  prove  valuable.  The  bowels  should  be  kept  free,  and 
the  patient  should  maintain  the  recumbent  position;  in  case  the  pain 
is  aggravated  by  locomotion,  she  should  have  the  necessary  exercise 
by  massage.  In  regard  to  alteratives,  which  are  expected  to  act 
more  directly  upon  the  ovarian  inflammation,  I  can  only  say  that  I 
have  apparently  seen  benefit  derived  in  cases  that  were  treated  early 
in  the  progress  of  the  disease.  I  prefer  to  give  small  doses — say,  a 
fifteenth  of  a  grain — of  the  bichloride  of  mercury  thi*ee  times  a  day 
for"  a  week  or  two,  and  follow  that  with  iodide  of  iron  or  iodide  of 
sodium — the  latter  in  case  the  patient's  strength  is  not  greatly  re- 
duced. 

The  chloride  of  ammonium  and  the  chloride  of  gold  have  been 
recommended,  but  I  have  not  seen  any  benefit  derived  from  them. 
If  this  plan  of  treatment  fails  to  give  relief,  and  the  patient  is  suf- 
fering so  that  her  life  is  useless,  the  ovary  or  ovaries  should  be  re- 
moved.    In  case  that  only  one  ovary  is  diseased,  and  the  other  is 

31 


466  DISEASES   OF   WOMEN. 

normal,  the  affected  one  only  should  l)e  removed.  To  decide  which 
course  to  [)ursue  is  often  dilMcult,  and  must  always  depend  upon  the 
judgment  of  tlie  operator  to  decide  while  operating.  So  far  as  I  can 
learn,  there  is  less  likelihood  of  erring  in  removing  both.  Many  of 
the  cases  in  which  one  ov^ary  was  removed  have  had  subsequent 
trouble  mth  the  other. 

Displacement  of  the  Ovaries. — The  ovaries  have  been  found  dis- 
located in  a  variety  of  ways.  Cases  are  recorded  in  which  the  ova- 
ries descended  through  the  inguinal  canal  after  the  manner  of  the 
testicles.  The  most  interesting  of  these  is  one  reported  by  Percival 
Pott,  who  removed  both  ovaries  that  were  found  in  the  usual  posi- 
tion of  an  inguinal  hernia;  and  still  another  is  mentioned  by  Tait,  in 
which  the  ovary  found  its  way  outside  of  the  inguinal  ring,  and  there 
developed  a  cystic  tumor,  which  was  removed  by  a  S])anisli  surgeon. 
The  ovaries  have  been  found  dislocated  laterally  and  high  up  in  the 
pelvis.  They  are,  in  such  cases,  usually  fixed  in  the  malposition  by 
adhesions.  Hart  and  Barbour  mention  a  case  seen  in  the  practice 
of  Prof.  Simpson,  in  which  an  ovary  was  found  in  the  infundibulum 
of  an  inverted  ovary.  The  following  cases  were  published  in  the 
"  St.  Louis  Cour.  Med.,"  April,  18S6,\v  J.  C.  Tedford  : 

An  Ovary  expelled  from  the  Anus. — The  patient,  Mrs.  S.,  £ged 
about  twenty-eight  years,  had  been  married  nearly  ten  years,  and 
had  had  tlii-ee  children,  all  now  living,  and  three  miscarriages,  occur- 
ring eacb  time  at  an  early  period  of  uterogestation.  "While  being 
treated  for  inflammation  of  the  left  ovary,  metritis,  and  retroversion, 
November  27th,  a  sound,  meeting  no  obstruction,  was  introduced 
four  inches  into  the  uterine  canal.  January  9th  a  small  foetus  was 
expelled.  January  14th  she  asked  her  husband  to  assist  her  up  to 
the  chamber.  This  he  did,  when  she  was  taken  with  a  severe  tenes- 
mus or  disposition  to  strain,  and  had  severe  pains  in  the  abdomen. 
As  she  expressed  it,  she  could  not  resist  the  straining  efforts  until  a 
tumor  was  expelled  from  the  anus.  I  was  sent  for,  and  went  direct 
to  her  bedside,  and  found  her  lying  upon  her  side,  and  a  tumor, 
as  above  stated,  protruding  from  the  anus,  very  red  in  color.  It 
did  not  seem  large  enough  to  be  the  womb ;  but,  to  make  a  start 
toward  a  solution  of  the  case,  I  introduced  my  finger  into  the  vagina, 
and  found  the  womb  all  right,  but  higher  up  in  the  peh-is  than  com- 
mon for  it,  and  turned  to  the  side.  I  then  introduced  my  finger  into 
the  rectum,  and  discovered  that  the  tumor  had  a  pedicle  extending 
up  into  the  rectum  to  a  point  almost  as  high  as  could  be  reached 
^atli  the  index-finger,  but,  by  finn  pressure  upward,  I  could  feel  the 
pedicle  pass  over  a  shelf,  as  it  were,  out  of  the  bowel  through  a  rent 


DISEASES  OF  THE   OVARIES.  467 

in  the  rectum,  as  I  then  supposed  it  to  he.  Thi«  shelf  over  which 
the  pedicle  came  felt  to  he  iiia&sive  and  thicker  just  under  the  ])edi- 
cle  than  at  any  other  point  in  the  walls  surrounding  it.  The  tumor 
itself  seemed  to  he  much  larger  at  one  end  than  at  the  other.  It 
was,  as  l)efore  stated,  red  at  its  largest  end,  and  faded  in  color  toward 
the  smaller  end,  and  was  quite  solid  to  the  touch.  I  could  make 
nothing  out  of  the  tumor  hut  an  ovary.  Dr.  Faulk  confirmed  my 
diagnosis,  and  ligated  and  cut  away  the  tumor  or  cystic  ovary.  This 
prolapsus  was  not  attended  at  any  time  by  any  great  degree  of  haem- 
orrhage, but  the  operation  was  followed  by  a  constant  discharge  of 
bloody,  watery  fluid  from  the  rectum.  As  stated  before,  the  perito- 
neal coat  of  the  expelled  ovary  was  very  red  and  cone-shaped  ;  the 
further  from  the  womb  was  the  larger,  perhaps,  one  and  a  quarter 
or  one  and  a  half  inch  in  diameter,  tapering  down  at  the  other  end 
to  nearly  the  size  of,  or  perhaps  a  little  larger  than,  the  natural 
ovary,  and  more  solid.  On  opening  the  cyst,  it  was  found  to  be 
tilled  with  an  almost  transparent,  whitish  substance,  tinged  a  little 
yellow,  and  semi-solid  in  consistence.  This  substance  filled  the  tumor 
from  one  end  to  the  other,  showing  the  ovary  to  be  in  a  cystic  con- 
dition throughout.  The  coat  of  the  cyst  under  the  pentoneal  coat 
was  of  a  yellowish  white  color,  and  quite  firm  in  texture.  The  pa- 
tient was  put  upon  a  treatment  of  opium  and  quinine  internally,  and 
antiseptic  washes  for  the  vagina  and  swabbing  of  the  rectum  with 
the  same  solution. 

Later,  a  second  seeming  tumor  appeared  to  come  out,  and  was  a 
direct  continuation  of  tissue  from  just  above  the  pedicle  of  the  for- 
mer operation.  General  peritonitis  gradually  advanced,  with  con- 
stantly increasing  tympanites,  until  January  20,  when  death  quietly 
closed  the  scene  at  3.15  p.  m. 

Post-mortem  twenty-four  hours  after  death.  The  womb  and 
broad  ligaments  were  of  a  dark-red  color,  and  relaxed  in  texture. 
The  left  ovary  was  absent,  but  the  stump  from  which  it  had  been 
cut  was  very  conspicuous,  and  had  at  some  period  after  the  ligation 
and  amputation  of  the  ovary  slipped  out  from  the  ligature  into  the 
pelvic  cavity.  The  rectum  and  lower  portion  of  the  colon  up  as 
high  as  the  lower  ihac  fossa  were  quite  solid  and  firm  to  the  touch, 
as  if  filled  nearly  full  of  something.  What  was  that  something  i 
The  ligature  upon  the  stump  or  pedicle  showed  not  only  the  point 
of  entrance  of  the  ovary  into  the  bowel,  but  showed  as  well  that 
that  portion  of  the  bowel  was  invaginated.  This  gave  light  upon 
the  coming  down  of  the  second  tumor  into  the  rectum  on  the  third 
day  after  the  first  operation. 


408 


DISEASES  OF   WOMEN. 


Such  cases  are  so  very  rare  that  they  are  of  little  interest  except 
as  curious  tliin<;.<  wliich  may  ha})pcii. 

Prolapsus  of  the  Ovaries. — Downward  dislocation  of  the  ovaries 
is  (juite  a  coniinon  atfcctiou  compared  with  all  the  other  displace- 
ments. It  is  the  only  atfection  of  this  class  wliich  has  an  interest 
to  the  gynecologist  derived  from  the  frequency  of  its  occurrence  and 
the  great  suffering  to  which  it  gives  rise.  On  that  account  it  de- 
serves more  than  a  passing  notice,  such  as  I  have  given  to  the  other 
forms  of  displacement  of  the  ovaries. 

Prolapsus  of  the  ovaries  I  have  described  as  occurring  in  two 
degrees — complete  and  inc(jniplete.  This  classification  is  based  upon 
the  fact  that  displacements  of  the  ovaries  must  in  practice  have  the 
natural  division.  In  the  incomplete  form  the  ovary  has  simply  de- 
scended from  its  normal  position  until  it  has  reached  the  side  of  the 
sac  of  Douglas  or  the  utero-sacral  ligament,  where  it  lodges.  In  the 
complete  form  the  ovary  rests  in  the  most  dependent  portion  of  the 
sac  of  Douglas.     Fig.  189  shows  the  position  of  the  ovary  in  com- 


FiG.  189. — Ovary  displaced  and  bound  down  in  the  cul  de  sac  by  adhesione.     ro,  right 

ovary ;  lo,  left  ovary. 

plete  and  incomplete  prolapsus,  and  the  relation  of  the  prolapsed 
organ  in  relation  to  the  uterus  and  sac  of  Douglas.  The  figure 
also  shows  what  is  sometimes  found  in  practice — namely,  complete 
prolapsus  of  one  ovary  and  incomplete  prolapsus  of  the  other  occur- 
ring in  the  same  suhject.  While  prolapsus  of  both  ovaries  in  dif- 
fering degrees,  or  both  in  the  same  degree,  may  occur,  I  more  fre- 
quently find  one  displaced,  w^hile  the  other  is  in  its  normal  position 


DISEASES  OF  THE  OVARIES.  469 

The  left  is  the  one  most  frequently  disiilaced,  or  else  it  causes  the 
most  suffering,  and  on  that  account  attracts  more  attention  than  the 
right,  and  is  oftener  discovered. 

Prohipsus  necessitates  a  stretching  of  the  supports  of  the  ovary, 
or  it  may  be  an  elongation  from  an  increase  of  tissue,  the  result  of 
hyperplasia  or  new  development.  Prolapsus  does  occur  without 
complications  or  coexisting  aiiections,  which  cause  the  displacement. 
Such  cases  are  not  very  common,  and  they  are  probably  the  result 
of  arrest  of  development.  In  many  cases,  perhaps  the  majority, 
there  is  some  accompanying  affection  which  has  some  part  in  the 
causation  of  the  prolapsus.  The  ovary  itself  is  often  enlarged  from 
inflammation  or  some  degenerative  changes.  In  other  cases  the  sup- 
ports of  the  ovary  are  elongated  from  imperfect  involution  after  con- 
finement. Retroversion  of  the  uterus  is  also  frequently  associated 
with  prolapsus  of  the  ovary.  A  not  uncommon  and  a  very  unfor- 
tunate complication  is  the  formation  of  adhesions  from  peritoneal 
inflammation. 

Syinptomatology . — The  degree  of  suffering  arising  from  disloca- 
tion of  the  ovaries  is  extremely  varying  in  different  cases.  This  is 
due  largely  to  the  fact  that,  if  the  ovaries  are  quite  normal  and  sim- 
ply displaced,  but  little  inconvenience  is  experienced  by  the  patient. 
It  is  rare  to  find  this  state  of  things,  because  the  ovaries  are  often 
diseased,  or  else  displacement  soon  leads  to  congestion,  tenderness, 
and  pain.  As  a  rule,  then,  in  displacement  of  the  ovaries  there  is 
pelvic  tenesmus  and  pain  on  walking  or  standing,  relief  from  which 
is  obtained  by  the  recumbent  position.  In  this  the  history  differs 
from  inflammation  of  the  ovaries.  There  is  usually  backache  and  pain 
along  the  thighs,  and  pain  and  tenderness  during  and  after  sexual 
intercourse.  There  is  pain  after  defecation,  especially  when  the  left 
ovary  is  displaced,  which  is  most  frequently  the  case.  This  pain  is 
peculiar  and,  I  believe,  diagnostic.  It  comes  on  during  or  imme- 
diately after  the  action  of  the  bowels,  and  continues  for  an  hour  or 
two.  It  is  a  dull,  aching  pain  located  in  the  region  of  the  ovary, 
and  radiates  to  the  abdomen.  It  produces  in  many  cases  faintness 
and  nausea,  compelling  the  patient  to  lie  down  until  it  subsides.  It 
is  easily  distinguished  from  the  acute,  smarting  pain  due  to  haemor- 
rhoids or  fissure  of  the  anus,  on  account  of  its  location  and  character. 
There  is  in  some  cases  derangement  of  menstruation,  usually  menor- 
rhagia.  The  pain  in  the  ovary  is  generally  aggravated  at  the  men- 
strual period.  The  constitutional  symptoms  are  generally  produced 
from  the  confinement  of  the  patient,  made  necessary  by  the  suffer- 
ing caused  by  taking  active  exercise.     There  is  often  headache, 


47(1  DISEASES  OF  WOMEN, 

mental  depression,  indigestion,  and  aniemia,  ending  in  geuenil  de- 
bility. It  should  be  understood  that  the  symptoms  alone  will  imt 
suffice  to  make  a  diagnosis,  because  in  many  cases  they  arise  more 
directly  from  the  condition  of  the  ovary  rather  than  from  its  mal- 
position. 

Phi/i<ical  Sir/ns. — The  meth(jd  of  making  a  vaginal  examination 
by  the  touch,  to  detect  a  j^rolapsus  of  the  ovaries  is  as  follows :  The 
linger  should  be  carried  as  far  upward  on  either  side  of  the  cennx 
uteri  as  the  vaginal  wall  will  permit,  and  then  Ijrought  downward 
toward  the  sacrum,  so  that  if  the  ovary  is  disjilaced  it  will  be  caught 
between  the  examining  linger  and  the  sacrum.  In  that  way  it  can 
be  outlined  by  palpation,  and  its  sensitiveness  determined.  Its 
mobility  or  fixation  can  also  be  determined  in  this  way.  I  have 
frequently  found  while  teaching  my  class  of  post-graduates  that 
these  few  hints  would  enable  them  to  find  the  disi)laced  ovaries 
when  they  had  tried  in  vain  to  make  out  their  location.  "When  an 
ovary  is  completely  prolapsed,  it  is  found  directly  behind  the  cervix 
uteri  in  the  most  dependent  portion  of  the  sac  of  Douglas.  So  ex- 
actly central  is  the  position  of  the  ovary  that  in  most  of  my  cases  I 
could  not  tell  whether  it  was  the  right  or  left  ovary,  and  could  only 
settle  that  question  by  finding  the  other  one  in  its  normal  position. 
If  the  prolapsus  is  incomplete  the  ovary  is  found  on  one  side  of 
the  cervix  uteri,  usually  at  a  point  a  little  above  the  junction  of  the 
body  and  cervix.  In  complete  prolapsus  the  ovary  feels  not  unlike 
the  fundus  uteri,  and  gives  the  impression  of  retroflexion  of  the 
uterus.  The  distinction  can  be  made  by  the  peculiar  sensitiveness 
of  the  ovaiy  to  pressure,  and  by  the  fact  that  the  finger  can  usually 
be  insinuated  between  the  uteras  and  the  ovary.  Should  there  still 
be  a  doubt,  the  question  can  be  solved  by  passing  the  sound  which 
will  exclude  flexion  of  the  uterus. 

There  is  another  condition  which  proves  to  be  somewhat  puz- 
zling, that  is  complete  prolapsus  of  the  ovary  with  the  retro  verted 
uterus  lying  directly  upon  and  above  it.  In  one  such  case  which 
came  under  my  care,  I  was  able  to  make  out  the  true  state  of  affairs 
by  passing  the  sound,  and  while  it  was  in  place  raising  the  uterus 
far  enough  to  lift  it  off  the  ovary,  so  that  by  the  touch  I  could  dis- 
tinguish the  one  from  the  other. 

Prognosis. — The  prospect  of  permanently  overcoming  the  dis- 
placement depends  upon  the  length  of  time  that  the  malposition  has 
existed;  upon  the  condition  of  the  ovary,  whether  nonnal  or  diseased, 
and  whether  there  are  other  complications,  such  as  adhesions,  retro- 
vei*sion,  or  retroflexion  of  the  uterus.    In  recent  uncomplicated  cases 


DISEASES   OF  THE   OVARIES.  471 

a  permanent  restoration  may  be  effected  if  the  patient  can  be  kept 
under  treatment  for  a  sufficient  length  of  time.  In  complicated 
cases  all  ordinary  local  treatment  fails.  It  is  then  that  the  question 
of  advisability  of  removing  the  ovaries  comes  up  for  consideration. 
Should  the  patient  be  near  the  menopause,  she  may  be  carried  along 
past  that  change,  and  the  recovery  may  come.  In  younger  subjects 
the  ovaries  should  be  removed  if  all  else  fails  to  give  relief. 

Causation. — The  following  are  the  causes  of  displacement  of  the 
ovaries,  named,  as  far  as  my  knowledge  guides  me,  in  the  order  of 
their  frequency. 

Subinvolution ;  enlargement  of  the  ovaries  from  hypersemia, 
ovaritis,  or  other  affections  ;  displacements  of  the  uterus  ;  congenital 
maljjosition  from  derangements  of  development  and  growth.  In 
regard  to  subinvolution,  it  may  be  well  to  call  to  mind  the  fact  that 
in  the  puerperal  state,  the  ovaries — especially  the  left  one — are  very 
large,  nearly  twice  as  large  as  at  other  times,  and  if  care  is  not  taken 
to  secure  complete  involution  after  confinement  the  heavy  ovaries 
will  naturally  descend,  and  by  making  traction  upon  the  peritoneum 
and  ligaments  will  overstretch  them.  I  believe  also  that  subinvolu- 
tion of  the  broad  ligaments  will  permit  the  ovaries  to  descend  into 
the  pelvis  when  they  are  not  much  enlarged.  At  any  rate,  I  have 
found  the  ovaries  prolapsed  when  they  were  not  large,  but  when  the 
broad  ligaments  were  long  and  relaxed,  a  condition  which  followed 
confinement.  In  regard  to  the  other  causes  of  prolapsus  of  the  ova- 
ries they  are  sufficiently  clear  to  warrant  my  saying  nothing  more 
about  them. 

Treatment. — The  first  thing  to  do  is  to  ascertain  if  the  displaced 
ovary  is  movable  and  can  be  raised  up  to  its  normal  position.  If 
that  can  not  be  accomplished,  owing  to  adhesions,  then  there  is  little 
to  be  hoped  for  from  treatment.  When  the  ovary  is  movable  it  can 
be  placed  in  position  by  putting  the  patient  in  the  knee-chest  posi- 
tion, using  a  Sims's  speculum,  and  then  making  upward  pressure 
through  the  vaginal  wall  with  a  sponge  held  in  a  sponge-holder.  In 
short,  the  same  method  is  employed  as  in  restoring  a  retro  verted 
uterus.  To  keep  the  ovary  in  place  the  cotton  tampon  is  the  best. 
It  should  be  removed  every  forty-eight  hours,  and  two  or  three  times 
daily  the  patient  should  take  the  knee-chest  position  if  she  is  able  to 
be  up  from  bed  during  the  day.  The  use  of  the  tampon  in  this  way 
takes  much  time,  and  I  have  taught  several  of  my  nurses  to  use  it 
with  very  satisfactory  results. 

Prof.  Goodell  recommended  that  the  patient  should  separate  the 
labia  while  in  the  knee-chest  position,  in  order  to  distend  the  vagina 


472  DISEASES   OF   WOMEN. 

witli  air,  and  Dr.  C.  F.  Campbell  uses  for  the  same  purpose  a  glass 
tube  open  at  both  ends,  which  is  introduced  into  the  vaj^ina  before 
the  patient  takes  the  knee-chest  position.  1  have  tried  both  of  these 
methods  but  have  given  them  up  for  two  reasons :  In  the  first 
place,  because  distention  of  the  vagina  is  unnecessary.  In  the  knee- 
chest  position  the  pelvic  organs  will  rise  high  enough  and  assume 
their  normal  position  as  surely  with  the  vagina  closed  as  open  ;  of 
this,  any  one  can  satisfy  himself  by  making  an  examination  before 
and  after  this  position  has  been  assumed.  In  the  second  place,  I 
find  that  the  less  local  treatment  patients  give  themselves  the  better 
it  is  for  them.  The  first  medical  book  of  any  kind  that  I  ever  read 
was  entitled  "  Every  Man  his  own  Physician,"  by  one  Dr.  Buchan. 
It  was  a  very  useless  production,  but  had  the  good  effect  of  preju- 
dicing me  against  making  every  woman  her  own  gynecologist.  I 
much  prefer  the  tampon  and  the  knee-chest  position.  If  there  is 
retroversion  or  flexion  of  the  uterus  present  at  the  same  time,  that 
organ  should  be  replaced  each  time  that  tlie  tamjjon  is  changed. 
When  considerable  has  been  gained  by  the  above  treatment,  and  the 
ovaries  and  uterus  are  replaced  sufficiently  to  get  a  pessary  under 
them,  one  should  be  introduced.  The  form  of  instrument  and  the 
method  of  using  it  are  the  same  as  in  retroversion  of  the  uterus  and 
need  not  be  detailed  here.  I  have  tried  the  special  forms  of  pessa- 
ries recommended  by  Tait,  Munde,  and  others,  but  have  not  been 
able  to  do  as  well  with  them  as  with  the  instrument  which  I  employ 
in  retroversion  of  the  uterus.  In  a  few  cases  I  have  succeeded  in  forc- 
ing the  uterus,  ovaries,  and  vaginal  w^all  upward  and  backward,  thus 
giving  some  relief  for  a  time,  but  the  traction  upon  the  vaginal  wall 
causes  stretching,  and  when  the  pessary  is  removed  the  displacement 
returns  to  a  degree  as  great  if  not  greater  than  before. 

AVhile  this  local  treatment  is  employed  every  effort  should  be 
made  to  improve  the  patient's  general  health.  Rest  should  be  in- 
sisted upon,  in  the  recumbent  position  at  first,  and  as  the  case 
progresses  favorably,  short  stages  of  exercise  may  be  permitted. 
Throughout  the  whole  treatment  all  sexual  relations  should  be  pro- 
scribed. 

When  all  other  treatment  fails,  and  the  patient  still  remains  a  use- 
less invalid,  the  ovaries  should  be  removed.  Further  discussion  of 
the  removal  of  the  ovaries  will  be  given  in  speaking  of  ovariotomy. 


CHAPTER   XXYI. 

NEOPLASMS    OF    THE   OVAEY. 

I  HAVE  made  a  classification  of  the  morbid  growths  of  the  ova- 
ries which  I  believe  will  best  serve  the  practical  reqnireinents  of 
the  gynecologist,  although  it  may  not  be  quite  in  keeping  with  the 
arrangement  of  the  subject  usually  found  in  the  text-books.  In  fact, 
it  would  be  hardly  possible  to  make  any  classification  \Ahich  would 
agree  with  all  of  the  many  authorities  on  the  subject.  Nor  would  it 
be  possible  to  present  an  argument  in  favor  of  the  classification  which 
I  have  adopted  without  either  taking  more  time  and  space  than  I 
can  afford,  or  else  omitting  to  mention  the  statements  of  many 
whose  views  are  well  worthy  of  consideration.  I  am  obliged  to  sim- 
ply state  in  brief  that  which  to  my  mind  appears  necessary  to  the 
student  and  practitioner. 

The  first  class  is  made  up  wholly  of  cystic  tumors,  with  a  single 
exception,  to  which  I  shall  refer  later,  and  of  these  there  are  two 
varieties — follicular  cysts  and  adenoid  cystomata.  Both  of  thor-e  va- 
rieties occur  in  a  simple  and  in  a  compound  form.  Thuj  we  may 
have  {a)  simple  unilocular  cystoma,  and  (b)  simple  follicular  cysts,  or 
of  the  compound  form  we  may  have  (c),  multiple  follicular  cysts, 
{d)  multiple  cystoma,  {e)  multilocular  cystoma,  (/")  papillary  cys- 
toma, and  {g)  dermoid  cystoma  ;  and  also  (A)  fibrous,  and  {i)  cysto- 
fibroma. 

The  second  class,  which  many  speak  of  as  malignant  gro^vths, 
contains  four  varieties :  {a)  carcinoma,  (b)  cysto-carcinoma,  (c)  sar- 
coma, and  id)  cysto-sarcoma. 

Classification. — These  morbid  growths  I  have  arranged  in  two 
classes : 

1.  Those  that  are  most  frequently  seen  in  practice,  and  that  are 
amenable  to  surgical  treatment. 

2.  Those  that  are  rarely  met  with,  and  that  resist  all  kinds  of  sur- 
gical treatment,  and  tend  by  their  very  nature  to  a  fatal  termination. 


474  DISEASES   OF   WOMEN. 

Tumors  of  the  first  class  are  spoken  of  by  some  authorities  aa 
beuigu,  wliile  they  apply  the  term  maliguaut  to  those  which  I  have 
placed  in  my  second  class. 


OVARIAN   CYSTS. 

Patholoijij. — The  kind  of  ovarian  neoplasm  most  frequently  seen 
is  the  cystic  tumor,  or  ovarian  cyst,  as  it  is  generally  called.  The 
simple  cyst  is  the  most  easily  comprehended,  and  M'ill,  therefore,  be 
first  described.  It  is  composed  of  the  cyst  proper  and  the  pedicle. 
The  cyst  is  made  up  of  the  cyst-wall  and  the  contained  tlnid. 

The  pedicle  is  usually  composed  of  the  ovarian  ligament,  Fallo- 
pian tube,  and  part  of  the  broad  ligament.  The  cyst  and  the  pedi- 
cle have  one  covering  in  common — namely  the  peritonajum. 

Simple  Cysts. — The  simple  cyst  is  usually  globular  in  form,  and 
its  walls  are  generally  of  uniform  thickness.  The  size  varies  in  dif- 
ferent cases  from  a  microscopic  object  to  one  weighing  one  hundred 
pounds  or  more,  according  to  the  age  of  the  growth.  The  term  sim- 
ple or  unilocular  cyst  is  not  intended  to  imply  that  the  tumor  is  ab- 
solutely composed  of  a  single  cyst,  since  it  is  believed  by  the  best 
authorities  that  ovarian  cysts  are  always  multiple,  but  the  term  sim- 
ple or  unilocular  is  applied  to  that  variety  of  cyst  which  in  its  gross 
anatomy  appears  to  be  single,  and  which  can  be  managed  by  the  sur- 
geon as  a  single  cyst.  The  one  sac  or  cyst  is  large  and  appears  to 
be  single,  but  on  close  inspection  minute  cysts  are  generally  found 
in  varying  numbers  in  the  major  cyst  or  in  that  portion  of  it  wdiich 
joins  the  pedicle. 

Compound  Cysts. — These  are  distinguished  from  the  simple  vari- 
ety by  being  multiple — that  is,  the  whole  tumor  or  mass  is  formed 
by  the  aggregation  of  several  simple  cysts,  each  being  large  enough 
to  be  easily  recognized.  The  usual  form  of  this  multiple  variety  of 
cyst  is  that  in  which  one  of  the  divisions  or  cysts  is  much  larger 
than  all  the  others  taken  together.  The  greater  contains  the  lesser 
ones  which  are  usually  formed  in  a  cluster  attached  to  one  side  of 
the  major  cyst,  near  the  pedicle. 

It  will  be  observed  that  the  difference  between  the  single  and 
multiple  cyst  is  that  in  the  former  there  are  a  number  of  well-de- 
fined cysts,  one  large  one  and  a  number  of  others  varying  in  size 
from  that  of  a  man's  head  to  a  small  hazel-nut,  while  the  latter  is 
composed  of  one  cyst  with  a  few  almost  imperceptible  cysts. 

Multilocular  Cysts. — These  are  so  called  because  the  sacs  or  cysts, 
which  in  the  aggregate  make  up  the  whole  tumor,  are  larger  in  size 


NEOPLASMS  OF  TUE  OVARY. 


475 


Fig.  190. — Left  ovary  distended  into  one  large  cyst,  into  the  interior  of  which  smaller 

cysts  project  (Farre). 

and  more  nearly  equal.     The  general  appearance  of  the  mass  is  of 
one  large  cyst-wall  containing  a  number  of  cysts  which  vary  in  size. 
Sometimes  one  or  more  of  the 
cysts  is  much   larger  than  the 
others.     In  other  cases  there  are 
several    cysts   varying  in    size 
from  that  of  a  human  head  to 
tliat  of  an  orange,  with  a  large 
number  of  smaller  cysts.    From 
the  general  appearance  and  ar- 
rangement it  would  appear  that 
the  cysts   included  within  the 
major  cyst- wall  had  been  devel- 
[oped  from  the  inner  cyst-wall, 
land  others  still  had  been  devel- 
loped  from  the  second  crop  by  a 
jrocess  of  endogenous  prolifer- 
'ation.     This  may  or  may  not  be 
the  fact,  but  it  is  more  likely 
that  the  ovary  from  which  the 
morbid    growth    is    developed 
contains  a  number  of  germs  in- 
icluded  in  the  structure  of  the 
[ovary  which  form  the  cyst-wall, 
land  that  they  all  grew  from  sim- 
lilar  germs  and   are  aggregations  rather  than  proliferations. 


Fig.  191. — Compound  and  proliferatinc 
(Farre). 


cyst 


The 


476 


DISEASES   OF   WOMEN. 


gross  appearance  of  such  tumors  is  the  chief  point  of  interest  to 
the  surgeon,  and  that  is  one  cyst-wall  containing  within  it  a  number 
of  cysts ;  usually,  there  are  one  or  two  large  cysts,  a  larger  number 
of  medium  size,  and  a  very  great  number  of  small  ones,  varying 
in  size  and  united  to  each  other.  The  cavities  of  these  cysts  rarely 
communicate  with  each  other ;  occasionally  a  cyst  is  found  the  cavi- 


FiG.  192. — Miiltilocular  cyst  (Hooper). 

ty  of  which  is  divided  by  septa,  but  associated  with  such  there  is 
always  a  number  of  independent  cysts. 

Complex  Cystoma. — These  tumors  are  called  complex  or  mixed 
because  they  differ  from  those  already  described  by  the  addition  to 
the  cyst  structures  of  other  pathological  elements,  or  else  there  is  a 
marked  development  of  some  special  portion  of  the  cyst  elements, 
the  cyst-wall  for  example. 

These  peculiar  portions  of  the  growth  may  consist  of  a  hvper- 
trophic  increase  in  the  tissues  of  an  ovarian  follicle  or  of  hypertrophy 
of  the  stroma  of  the  ovary,  infiltrated  with  serum  or  other  morbid 
fluids.  Proliferation  of  the  fibrous  tissue  may  give  rise  to  one  or 
more  fibrous  masses  connected  with  the  cyst.  The  cyst-wall  may 
be  greatly  thickened  generally,  or  in  certain  portions,  from  hyper- 
trophy of  either  its  inner  or  middle  layer.  The  inner  surface  or 
lining  membrane  of  a  cyst  may  develop  new  structures  or  pro- 
liferations. Again,  the  contents  of  a  cyst  may  be  of  a  character 
entirely  different  from  the  ordinary  fluid  found  in  simple  or  com- 
pound cystic  tumors.  In  this  way  the  following  complex  tumors 
are  formed. 

Papillary  Cysts. — In  this  form  of  cyst  the  connective  tissue  of 
the  cyst-wall  undergoes  hyperplasia  in  certain  places,  and  the  growth 
of  the  tissue  pushes  the  lining  membrane  of  the  cyst  before  it,  and 


NEOPLASMS   OF   THE   OVARY. 


477 


in  that  way  a  great  number  of  papillce  are  found  projecting  into 
the  major  cyst  and  covering,  it  may  be,  the  whole  interaal  surface 


Fig.  193. — Papillary  cystoma  of  ovary  showing  proliferation  (Winckel). 

of  the  sac.     The  papillse  are  sometimes  very  vascular,  and  are  cov- 
ered with  columnar  epithelium. 

Dermoid  Cysts. -^The  characteristics  of  these  tumors  differ  very 
markedly  from  those  already  described.  The  genesis  of  this  cyst  is 
peculiar,  and  this  may  account  for  the  fact  that  its  contents  are  made 


Fig.  194. — Dermoid  cyst  of  ovary,  filled  with  hair  and  tallow-like  masses  (Winckel). 

up  of  specimens  of  most  of  the  tissues  of  the  body ;  hair,  bone, 
teeth,  and  adipose  tissue  are  usually  in  the  greatest  abundance. 

Cysto-Fibroma. — In  this  form  of  tumor,  the  fibrous  portions 
closely  resemble  in  structure,  fibrous  tumors  of  the  uterus.  They 
do  not  differ  in  their  outward  appearance  from  the  ordinary  simple 
cyst,  but  the  touch  shows  that  part  of  the  mass  is  solid  and  the  other 
fluid.  These  morbid  growths  are  quite  rai'e.  I  have  only  met  with 
one  in  my  own  practice. 


478 


DISEASES   CF   WOMEN. 


FIBROMA    OF    THE    OVARY. 

This  rare  form  of  ovarian  tumor  I  have  classed  with  the  cys- 
tomata  not  because  it  presents  any  features  in  common  with  the 
class,  except  that  it  calls  for  surgical  interference  and  does  not  in 
any  way  belong  to  the  second  class,  having  no  inherent  tendency  to 
prove  fatal  except  by  indirect  effects.  It  is  rare,  and  hence  not  oi 
sufheient  importance  to  demand  a  separate  cla^  for  itself  alone.  In 
describing  this  form  of  neoplasm  I  may  say  that  it  is  like  the  cysto- 
fibroma,  minus  the  cyst  or  cysts.  The  composition  of  the  growth  is 
similar  to  the  fibroid  tumors  of  the  uterus.  That  the  fibroma  of 
the  ovary  is  very  closely  related  to  the  cysto-fibroraa  is    further 


fij^l^l0imiL        HiMterz  Vt^rasvmnd/. 


Tumav 


EiyerstotKs. 


Obe^fidc/i^.d.lE. 


£UrstcvfCs. 


Fig.  195. — Fibroma  afPccting  both  ovarie.'s  (Winckel). 

shown  from  the  fact  that  so-called  fibromata  have  been  found  with 
small  cysts.  In  the  one  the  cyst  element  ])redominates  while  in  the 
other  the  solid  or  fibrous  element  is  the  principal  or  only  one  found. 
Cyst-Wall. — The  walls  of  the  cysts  of  ovarian  tumors  are,  as  a 
rule,  nearly  all  the  same.  For  convenience  of  description  and  for 
the  purposes  of  the  surgeon  the  wall  is  divided  into  three  layers. 
Tlie  e\i;enial  is  a  serous  membrane  corresponding  to  the  peritonreum 
which  it  is  in  fact.  The  middle  coat  is  areolar  tissue,  and  contains 
the  main  blood-vessels  of  the  cyst.     The  internal  layer  is  like  the 


NEOPLASMS   OF  THE  OVARY.  479 

external  so  far  as  its  fibrous  elements  are  concerned,  but  it  is  really 
a  mucous  membrane.  It  is  less  uniform  tlian  the  other  layers  in 
appearance,  and  usually  contains  small  cysts  in  process  of  develop- 
ment or  follicles  which  have  undergone  degeneration.  Papilla;  are 
often  found  developed  on  this  layer  as  already  stated.  "While  this  in 
a  general  way  describes  the  cyst- walls,  they  are  subject  to  certain 
modifications  as  follows :  The  middle  layer  which  is  well  defined  at 
the  base  of  the  tumor  contains  the  large  vessels  and  is  easily  sepa- 
rated from  the  peritoneal  layer.  It  becomes  thinner  the  farther  it 
departs  from  the  pedicle,  and  when  it  reaches  about  the  middle  of 
the  tumor  there  are  only  two  layers  easily  distinguished,  while  at 
the  summit  there  is  only  one  that  can  be  made  out  by  ordinary  dis- 
section. 

While  the  middle  layer  diminishes  gradually  as  it  gets  farther 
and  farther  away  from  the  base  and  finally  disappears,  the  internal 
and  external  layers  come  together  and  are  united  and  increase  in 
thickness  so  that  the  cyst-wall  becomes  a  fibrous  homogeneous  mem- 
brane. Some  authors  have  made  more  minute  subdivisions  of  the 
layers  of  the  cyst-wall  but  that  1  look  upon  as  a  super-refinement  in 
dissection  which  has  no  value  in  this  connection. 

The  outer  and  inner  coats  are  often  modified  in  appearance  and 
character.  The  external  layer  is  changed  in  places  by  circumscribed 
peritonitis,  or  by  great  vascularity,  and  the  internal  coat  is  often 
changed  by  inflammatory  action,  degeneration,  or  hyperplasia. 

The  appearance  of  the  outer  coat  has  a  special  interest  for  the 
surgeon.  To  be  able  to  recognize  the  cyst-wall  when  one  comes  to 
it  in  operating  is  very  important.  Many  times  in  simple  uncompli- 
cated cases  the  cyst-wall  is  smooth,  of  a  whitish  color,  slightly  tinged 
\nth  a  pinkish,  pearly  tint  which  resembles  the  peritonaeum,  every- 
where covering  the  abdominal  viscera,  and  yet  easily  distinguished. 
When  there  has  been  peritonitis  the  cyst-wall  becomes  covered  with 
lymph  or  adhesions,  and  so  changed  in  appearance  that  it  is  difficult 
to  recognize  it  when  it  is  reached,  owing  to  the  products  of  inflam- 
mation. The  vascularity  of  the  outer  coat  of  the  cyst  varies  greatly. 
Sometimes  the  whole  surface  presents  a  fine  network  of  vessels  all 
over  the  parts  that  are  seen,  in  other  cases  the  vascularity  is  exag- 
gerated in  patches.  This  great  vascularity  when  it  occurs  without 
preceding  evidence  of  inflammation  makes  a  marked  contrast  between 
the  cyst  and  the  abdominal  viscera  w^hich  enables  one  to  promptly 
distinguish  the  one  from  the  other.  In  a  few  tumors,  all  of  them 
occurring  in  oldish  patients,  I  have  found  large  portions  of  the  cyst- 
wall  of  a  pale,  grayish-white  color  without  any  recognizable  vascu- 


480  DISEASES  OF  WOMEN. 

lanty.  Tliis  made  tlie  cyst  very  peculiar  in  appearance  and  easily 
recognized.  This  rare  and  peculiar  C(jlor  is  caused  by  commencing 
necrosis. 

Contents  of  Ovariau  Cysts. — The  contents  of  the  simplest  variety 
of  cyst  are  a  serous  liuid  of  a  lemon  or  amber  color,  but  subject  to 
marked  variation  in  different  cases.  The  character  of  the  fluid  is 
modified  by  the  size  of  the  cyst,  the  length  of  time  it  has  existed, 
and  uhethcr  the  cyst  has  been  tapped  ;  under  these  modifying  intiu- 
ences  the  fluid  may  be  colorless,  or  chocolate-colored  from  the  pres- 
ence of  blood  in  varying  quantity,  or  it  may  be  of  a  greenish-yellow 
color,  from  the  presence  of  pus  produced  by  inflammation  of  the 
cyst.  Shreds  and  flakes  of  whitish  lymph  are  sometimes  found  with 
the  pus  when  there  has  been  inflammation.  Occasionally,  the  fluid  is 
viscid. 

It  generally  contains  albumen  or  paralbumen,  and  sometimes 
crystals  of  cholesterine  are  found  in  it.  The  contents  of  the  multi- 
locular  cysts  resemble  those  just  described,  presenting  the  same  dif- 
ferences in  different  patients.  Usually  the  fluid  is  more  viscid  or 
gelatinous,  sometimes  quite  thick  so  that  it  escapes  \nth  difficulty. 
In  one  case  I  found  the  cyst  contents  exactly  like  jelly  but  different 
in  character  in  this,  that  jelly  is  friable,  but  this  material  was  ex- 
ceedingly tenacious,  so  that  it  could  not  be  pressed  out  of  the  sac, 
and  was  even  pulled  out  with  the  hand  with  great  difficulty.  The 
fluid  in  the  several  cysts  of  a  multilocular  tumor  is  not  always  the 
same.  It  often  differs  in  color  and  consistency  in  the  different  di- 
visions of  the  tumor.  In  addition  to  the  albumen,  blood,  cholester- 
ine, pus,  and  lymph,  which  may  be  present  in  the  fluid  of  ovai-ian 
cysts,  there  are  other  chemical  and  anatomical  elements  found  which 
are  of  interest. 

The  contents  of  ovarian  cysts  have  been  most  thoroughly  investi- 
gated as  to  their  chemical  composition  by  Eichwald.  As  has  already 
been  stated  they  may  be  as  fluid  as  senun,  or,  as  is  more  often  the 
case,  viscid  sometimes  to  such  a  degree  as  to  be  gelatinous  in  con- 
sistency. The  specific  gra\aty  may  be  as  low  as  1007,  or  as  high  as 
1020.  There  are  two  distinct  classes  of  elements  which  occur  in 
the  contents  of  these  cysts :  the  one  mucous  in  its  nature,  which 
predominates  in  the  younger  cysts,  the  other  albuminous,  which  is 
characteristic  of  the  large  and  older  colloid  cysts.  The  colloid  sub- 
stance is  regarded  as  a  modified  mucine  formed  from  the  substance 
of  the  colloid  bodies  and  the  parenchyma  of  the  cells  of  the  ovaries. 
Colloid  degeneration  is  therefore  but  another  name  for  mucous 
metamorphosis.      The  first,  or  mucine  class,  consists  of  four  ele- 


^ 


NEOPLASMS  OF  THE   OVARY.  481 

nients ;  the  substance  of  the  colloid  corpuscles,  mucines,  colloid  sub- 
stance, and  niuco-peptoue.  These  are  distinguished  Ijy  their  solu- 
bility in  water,  and  by  various  reactions  which  need  not  be  men- 
tioned here. 

The  second  or  albuminous  class  is  characterized  by  the  presence 
in  the  contents  of  the  cysts  of  free  albumen  and  the  albuminate  of 
soda.  In  colloid  tumors  the  free  albumen  becomes  albuminoid  pep- 
tone, while  the  albuminate  undergoes  no  change.  The  conversion  of 
free  albumen  takes  place  slowly;  it  first  becomes  paralbumen,  then 
metalbumen.  These  are  not  fixed  bodies,  but  pass  on  to  the  condi- 
tion of  peptone.  Thus,  the  albuminous  elements  which  are  found  in 
this  albuminous  class  are  albuminous  paralbumen,  metalbumen,  and 
albuminoid  peptone.  In  a  chemical  analysis  of  the  contents  of  a 
cyst,  Eichwald  found  the  following  to  be  its  composition  : 

Water 931-96 

Organic  substances 59*77 

Potass,  sulph. '08 

"        chlor -59 

Sod.  nit 6-29 

"    phosph °16 

"    carb -38 

Salts  insoluble  in  water '74: 

Loss '03 


1000-00 


MICROSCOPIC    CONTENTS    OF    OVARIAN    CYSTS. 

Under  the  microscope  the  contents  of  different  cysts  present  very 
different  appearances.  The  cell  elements  abound  in  those  which  are 
colloid  in  their  nature,  while  those  which  are  serous  are  very  defi- 
cient in  this  respect.  Eichwald  in  one  of  the  colloid  cysts  found  so 
large  an  amount  of  corpuscular  elements  that  he  was  unable  to  ex- 
amine it  satisfactorily  with  the  microscope  until  he  had  diluted  it 
with  water.  When  thus  treated  he  found  fatty  elements,  round  and 
serrated  cells,  large  colloid  cells,  round  cells  resembling  those  de- 
scribed by  Lebert  as  pyoid  bodies,  and  Henle  as  exudation  corpus- 
cles ;  globular  aggregations  of  various  sizes,  scales  of  epithelium, 
crystals  of  cholesterine,  and  brown  pigment  were  also  found.  As  a 
rule  the  morphological  elements  found  in  the  fluid  of  ovarian  cysts 
are  granular  cells,  free  granules,  small  oil-globules,  epithelial  cells, 
blood-corpuscles,  Gluge's  corpuscles,  and  pus  cells.  From  time  to 
time  various  cells  have  been  described  as  characteristic  of  the  ovarian 

32 


482  DISEASES  OF  WOMEN. 

cyst.  Amoiifij  others  Drysdale  has  described  such  a  cell  which  he 
speaks  of  as  "  the  ovarian  granular  cell,"  and  which  he  regards  as 
pathognomonic  of  ovarian  disease.  His  claim  to  the  discovery  of 
this  cell  is  thus  put :  "  I  claim,  then,  that  a  granular  cell  has  been 
discovered  by  me  in  ovarian  fluid,  which  differs  in  its  behavior  with 
acetic  acid  and  ether  from  any  other  known  granular  cell  found  in 
the  abdominal  cavity,  and  which  by  means  of  these  reagents,  can  be 
readily  recognized  as  the  cell  that  has  been  described  ;  and,  further, 
that  by  the  use  of  the  microscope,  assisted  by  these  tests,  we  may 
distinguish  the  fluid  from  ovarian  cysts  from  all  other  abdominal 
dropsical  fluids." 

This  "ovarian  granular  cell"  of  Drysdale  is  generally  round, 
but  sometimes  oval,  is  very  delicate  and  trans])arent,  and  contains  a 
number  of  fine  granules  but  no  nucleus.  The  size  of  the  cell  varies 
from  ^,^^  inch  to  ^,77-5-5^  inch.  When  acetic  acid  is  brought  in 
contact  with  this  cell,  it  becomes  more  transparent,  and  its  granules 
appear  more  distinct.  On  the  other  hand,  when  thus  treated  with 
acetic  acid  it  becomes  larger,  and  from  one  to  four  nuclei  appear. 
It  is  distinguished  from  Gluge's  inflammation  corpuscle  by  the  fact 
that  when  ether  is  added,  the  ovarian  cell  is  unaffected  ;  at  most,  has 
its  granules  made  paler,  while  Gluge's  corp)uscle  loses  its  granular  ap- 
pearance, and  sometimes  entirely  disappears  through  a  solution  of  its 
contents  by  the  ether.  In  reference  to  this  subject  it  may  be  said 
that  the  views  of  Drysdale  deserve  the  most  careful  consideration, 
but  I  am  not  as  yet  satisfled  in  my  own  mind  that  this  corpuscle  is 
pathognomonic  of  ovarian  disease,  nor  indeed  that  the  diagnosis  can 
be  positively  made  by  either  chemical  or  microscopical  analysis. 

Causation. — The  development  and  growth  of  ovarian  cysts  and 
cystomata,  vary  in  different  cases  in  many  respects,  and  still  there 
is  a  certain  sameness  in  the  majority.  The  growth  of  these  has  been 
divided  into  three  stages,  the  division  being  based  upon  certain  feat- 
ures of  the  natural  history  of  these  neoplasms  rather  than  upon  any 
changes  in  their  pathology.  In  the  first  stage  the  tumor  is  small 
and  confined  to  the  pelvic  cavity.  This  stage  begins  with  the 
formation  of  the  morbid  growth  and  ends  when  it  is  large  enough 
to  rise  out  of  the  pelvis  into  the  abdominal  cavity.  The  duration  of 
this  stage  can  not  be  estimated  because  there  is  no  way  by  which  the 
morbid  growth  can  be  detected  until  it  has  attained  considerable 
size.  In  many  cases  an  ovarian  tumor  gives  rise  to  no  mai'ked  dis- 
turbance and  therefore  remains  unnoticed  until  it  has  reached  the 
second  stage.  This  stage  begins  when  the  tumor  rises  up  into  the 
abdomen,  and  ends  when  the  patient's  general  health  begins  to  suf- 


NEOPLASMS   OF  THE  OVARIES.  483 

fer  from  it.  These  constitutional  effects  of  the  morbid  growth 
mark  the  beginning  of  the  third  stage.  Tiie  first  stage  often  passes 
by  witlioiit  the  presence  of  anything  wrong  being  suspected.  It 
is  only  when  pressure  upon  the  pelvic  organs  or  when  some  inflam- 
matory action  in  the  ovary  or  pelvic  peritonaeum  occurs,  that  there 
is  any  likelihood  of  the  affection  being  discovered.  There  is  reason 
to  believe  from  the  cases  which  have  been  watched  that  the  growth 
is  steadily  progressive  as  it  is  in  the  others.  The  natural  history  of 
non-malignant  tumors  is  that  they  go  on  gradually  increasing  until 
they  attain  a  size  sufticient  to  destroy  life.  This  requires  from  two 
to  three  years  on  the  average,  but  there  is  a  great  variation  in  time 
in  different  cases.  There  are  periods  of  standing  still  followed  by 
rapid  increase  in  size.  These  alternations  of  increase  and  passive- 
ness  may  occur  repeatedly  or  the  progress  may  be  continuous. 

In  the  third  stage  the  general  health  of  the  patient  begins  to  suffer. 
There  is  usually  loss  of  flesh  and  the  face  shows  evidence  of  ill- 
health.  A  certain  facial  expression  has  been  described  as  the  facies 
ovarii,  but  this  is  diflicult  to  describe  or  recognize.  It  may  be  said 
to  be  an  emaciated,  careworn  appearance  without  the  bronze  hue  of 
the  cachectic  state.  This  •  malnutrition  is  due  at  first  to  exhaustion 
from  the  growth  of  the  tumor,  and  finally  to  pressure  upon  the 
neighboring  organs.  The  functions  of  the  abdominal  and  thoracic 
organs  become  deranged  from  pressure,  and  cause  exhaustion  and 
death  by  slow  degrees. 

Death  sometimes  comes  suddenly  from  asphyxia  due  to  pressure 
upon  the  thoracic  organs.  Sometimes  peritonitis  produces  the  im- 
mediate cause  of  death.  In  the  majority  of  cases  that  are  permitted 
to  run  their  course,  the  patient  is  slowly  crowded  out  of  existence 
by  the  enormous  size  of  the  tumor.  Fortunately,  there  are  few  cases 
in  this  age  that  are  permitted  to  be  lost  in  this  way. 

Toward  the  end  of  the  third  stage  oedema  of  the  limbs  generally 
appears.  This  is  more  likely  to  occur  if  the  patient  is  unable  to  lie 
down  in  bed. 

Complications. — There  are  certain  pathological  changes  which 
occasionally  occur  during  the  progress  of  an  ovai'ian  tumor  which 
may  be  considered  as  complications  of  the  original  affection.  The 
presence  of  an  ovarian  tumor  tends  to  excite  circumscribed  inflam- 
mation of  the  peritonaeum  which  gives  rise  to  adhesions  of  the  cyst 
or  tumor  to  the  pelvic  or  abdominal  viscera.  This  is  the  most  fre- 
quent complication  and  one  which  is  of  exceeding  interest  to  the 
surgeon.  The  location,  extent,  and  firmness  of  the  adhesions  differ 
greatly  according  to  the  duration,  size,  and  character  of  the  cyst  or 


484:  DISEASES  OF  WOMEN. 

tuiiior.  It  is  also  possible  that  the  state  of  the  patient's  constitution 
luid  general  health  may  have  some  influence  in  determining  the 
development  of  inflammatory  adhesions.  In  regard  to  the  effect 
•which  the  nature  of  the  tumor  has  upon  the  occurrence  of  adhesions 
mv  observations  lead  me  to  believe  that  malignant  growths  and 
those  that  are  mixed — that  is,  in  part  benign  and  in  part  malignant 
— are  most  frequently  found  to  have  adhesions.  It  is  also  a  ques- 
tion whether  the  adhesions  found  by  some  of  these  neoplasms  result 
in  all  cases  from  peritoneal  inflammation.  In  some  cases  that  I 
have  seen  it  appeared  to  me  that  the  ovarian  tumor  became  attached 
to  the  viscera  in  contact  with  it  by  an  extension  of  the  ovarian  dis- 
ease. It  may  be  that  in  such  cases  the  malignant  disease  may  have 
begun  in  other  organs  and  tissues  as  well  as  in  the  ovary,  and  that 
the  diseased  parts  became  united  without  intervening  products  of 
inflammation  ;  occasionally  adhesions  occur  where  the  tumor  is  small, 
and  then  they  are  found  in  the  pelvis  or  in  relation  with  the  lower 
intestines.  "When  they  take  place  after  the  tumor  is  large  enough 
to  distend  the  abdominal  walls  they  are  found  higher  up.  Then  the 
tumor  may  be  adherent  to  the  abdominal  wall,  omentum,  stomach, 
loin,  diaphragm,  or  to  the  lumbar  region.  Such  extensive  adhesions 
are  rather  rare,  still  they  occur  sufiiciently  often  to  be  of  the  great- 
est interest  to  the  surgeon.  These  adhesions  sometimes  displace  the 
pelvic  organs  and  derange  their  functions.  When  a  small  tumor 
becomes  adherent  to  the  uterus  or  bladder  it  will  carry  these  organs 
up  out  of  place  when  it  grows  larger  and  rises  up  into  the  abdominal 
cavity. 

Obstruction  of  the  intestines  may  be  caused  by  the  traction  of 
adhesions  and  also  by  tlie  pressure  of  a  very  large  tumor.  Occasion- 
ally a  small  tumor  in  the  pelvis  may  make  pressure  upon  the  rectum 
sufficient  to  obstruct  the  action  of  the  bowels,  but  that  is  rather  rare, 
unless  the  tumor  is  so  firmly  fixed  by  adhesion  that  it  can  not  be  dis- 
lodged. Rotation  of  the  tumor  upon  its  axis  occasionally  takes  place. 
This  produces  twisting  of  the  pedicle  and  partial  or  complete  stran- 
gulation of  the  blood-vessels  and  tissues  of  the  pedicles.  The  result 
is  that  the  blood  can  not  return  from  the  tumor,  and  hence  the  ves- 
sels become  overdistended  and  sometimes  rupture  follows.  The 
bleeding  into  the  cyst  suddenly  distends  it  and  causes  shock.  Some- 
times the  cyst  ruptures  under  the  pressure  of  the  haemorrhage  with- 
in it  and  death  may  take  place.  Cases  have  been  known  of  haemor- 
rhage into  the  cyst  which  have  proved  fatal  from  shock  and  loss  of 
blood  without  the  cyst  bursting.  Should  the  patient  withstand  the 
shock  and  haemorrhage,  peritonitis  and  cystitis  are  likely  to  occur. 


NEOPLASMS   OF  TOE  OVARIES.  485 

Death  takes  place  as  a  rule,  if  the  twisting  of  the  pedicle  is  suffi- 
cient to  completely  arrest  the  circulation.  This  proves  fatal  unless 
the  tumor  is  removed.  If  the  twisting  is  not  sufficiently  marked  to 
arrest  the  nutrition  of  the  tumor  suddenly  and  completely  atrophy 
may  take  place  instead  of  gangrene  or  necrosis.  Spontaneous  cure 
has  taken  place  in  this  way,  the  tumor  shriveling  up  and  disappear- 
ing. Some  very  curious  things  have  hapj^ened  from  twisting  of  the 
pedicle.  Atroj^hy  has  taken  place  so  perfectly  that  the  pedicle  has 
been  severed,  the  tumor  becoming  entirely  free  from  all  attach- 
ments. 

More  strange  things  still  have  happened.  The  tumor  has  be- 
come adherent  to  some  part  of  the  abdominal  viscera  and  subse- 
quently the  pedicle  has  become  separated  from  the  tumor  by  a  pro- 
cess of  slow  atrophy.  While  the  separation  of  the  pedicle  is  slowly 
disappearing  the  vascularity  increases  at  the  point  of  adhesion,  and 
the  tumor  derives  its  nourishment  from  its  new  attachment.  This 
has  been  described  as  transplantation,  a  term  which  clearly  indicates 
the  process  which  takes  place. 

Dragging  of  the  Pedicle  gives  results  similar  to  twisting.  This 
dragging  is  produced  usually  when  pregnancy  occurs  during  the  ex- 
istence of  an  ovarian  tumor.  The  uterus  growing  faster  than  the 
pedicle  pushes  the  tumor  upward  and  makes  strong  and  continuous 
traction  upon  the  pedicle  and  obstructs  the  vessels.  Again,  if  the 
ovary  is  adherent  in  the  pelvis,  and  the  pregnant  uterus  ascends, 
traction  will  be  made  sufficient  to  damage  the  nutrition  of  the  ovary 
and  any  cyst  that  may  exist  there.  There  is  another  way  in  which 
traction  of  the  pedicle  may  occur.  A  cyst  or  tumor  may  be  carried 
high  up  in  the  abdomen  with  the  pregnant  uterus,  and  become 
adherent  at  its  higher  part,  and  when  the  uterus  descends  after 
delivery  the  pedicle  may  become  stretched.  It  is  presumed  that 
cystic  tumors  may  become  atrophied  and  a  spontaneous  recovery  oc- 
cur. This  belief  is  based  upon  the  fact  that  in  old  women  the  ova- 
ries have  been  found  to  contain  shrunken  cysts  imbedded  in  very 
hard,  thickened  stroma  and  it  is  believed  that  this  condition  is  the 
result  of  atrophy  by  cystic  tumors.  There  is  no  absolute  proof  that 
absorption  of  the  fluid  and  shriveling  of  the  cyst-wall  occurs  except 
by  obstruction  of  the  blood-vessels  in  the  pedicle  as  already  de- 
scribed. 

Rupture  and  Perforation  of  Ovarian  Cysts. — Rupture  may  occur  as 
the  result  of  overdistention  of  the  cyst-wall  from  rapid  accumula- 
tion of  fluid  in  the  cyst,  or  from  injuries  such  as  du-ect  blows  or 
concussions  from  falling  or  sudden  exertion.     The  burstinc:  of  a 


486  DISEASES  OF  WOMEN. 

cyst  may  cause  deatli,  or  tlie  openinn^  may  be  closed  by  inflamma- 
tory exudation  and  the  cy.'^t  refill.  It  lia.s  also  been  claimed  that  the 
cyst  may  disappear,  and  the  patient  recover.  When  this  spontane- 
ous recovery  occurs  after  the  bursting  of  a  cyst,  there  is  always 
room  for  doubt  about  its  being  an  ovarian  cyst.  For  the  present 
it  must  remain  an  open  question  whether  ovarian  cysts  ever  disap- 
pear in  this  way.  It  is,  however,  well  known  that  cysts  of  the 
ovary  frequently  burst  and  empty  their  contents  into  the  abdominal 
cavity.  The  results  of  this  differ  greatly ;  sometimes  there  is  not 
much  trouble  if  the  fluid  is  clear  and  non-irritating;  in  other  cases 
death  is  caused  in  a  short  time  by  sliock,  or  peritonitis  may  follow 
and  cause  death  or  terminate  in  closing  the  opening  in  the  cyst  and 
forming  extensive  adhesions  of  the  cyst-  and  abdominal-walls  and 
viscera.  In  those  cases  which  recover  from  the  shock  of  rupture 
and  the  subsequent  peritonitis  and  the  cysts  refill  there  are  always 
extensive  adhesions  found. 

Perforation  differs  from  rupture  in  being  a  slow  process  and  in 
the  fact  that  the  opening  is  frequently  into  the  adjoining  viscera  of 
the  abdomen  or  pelvis.  There  are  two  ways  in  which  perforations 
occur ;  the  one  by  thinning  of  the  cyst-wall  from  pressure,  either 
from  within  the  cyst  or  from  without  at  a  given  point,  and  the  other 
and  most  frequent  by  suppuration  or  ulceration.  Perforation  occur- 
ring in  either  way  may  open  into  the  peritonseura,  but  in  case  the 
opening  is  the  result  of  suppuration  it  may  be  into  some  of  the 
neighboring  organs.  In  some  cases  the  perforation  is  very  small 
and  the  opening  is  closed  by  exudations  which  also  form  adhesions 
to  the  neighboring  organs.  This  fact  has  led  to  the  belief  that 
many  of  the  adhesions  found  are  the  result  of  these  small  perfora- 
tions which  admit  of  a  limited  escape  of  the  cyst  fluid.  Should  the 
perforation  be  large  a  free  escape  of  the  fluid  may  take  place,  and 
the  result  would  be  the  same  as  in  case  of  rupture.  When  the  ])er- 
foration  is  into  the  intestine,  the  contents  of  the  sac  may  be  wholly 
emptied,  but  this  form  of  perforation  is  rare. 

Another  rare  form  of  perforation  has  been  seen  in  which  a 
communication  between  an  ovarian  cyst  was  formed  by  ulceration 
extending  from  the  intestine  and  opening  into  the  cyst. 

Ovarian  Cystitis. — Inflammation  of  the  interior  of  the  cyst  occurs 
occasionally  and  is  a  serious  complication.  In  multiple  and  multi- 
locular  cysts  the  inflammation  is  usually  limited  to  one  or  more  of 
the  cysts,  the  others  in  the  tumor  remaining  in  their  original  condi- 
tion. The  inflammation  is  of  a  low  form  in  most  cases  and  ends  in 
suppuration ;  in  others  there  is  a  mixture  of  pus  with  shreds  and 


NEOPLASMS  OF  THE   OVARIES.  487 

flakes  of  lymph.  The  original  fluid  in  the  cyst  is  supplanted  to  a 
large  extent  by  these  products  of  inflammation. 

This  was  well  illustrated  in  a  case  of  a  monocyst  which  came  un- 
der my  care  years  ago.  I  tapped  the  cyst,  and  withdrew  a  half  a 
pint  of  clear  fluid,  inflammation  followed,  and  the  cyst  slowly  tilled 
up  but  did  not  increase  beyond  its  original  size.  It  became  adher- 
ent to  the  abdominal  wall  and  finally  opened  externally,  and  it  was 
then  found  to  be  filled  with  pus. 

In  another  case  a  hypodermic  syringe  full  of  clear  fluid  was 
drawn  off  from  the  major  cyst  of  an  ovarian  tumor,  and  then  inflam- 
mation followed,  and  the  patient  was  subsequently  brought  to  me 
for  operation.  I  found  pus  and  lymph  in  the  cyst,  but  the  most  of 
the  original  clear  fluid  had  disappeared. 

Abdominal  dropsy  is  still  another  complication  which  may  occur. 
There  is  in  many  cases  a  little  free  fluid  in  the  peritoneal  cavity 
which  is  not  of  special  interest,  but  in  other  cases  the  quantity  of 
fluid  is  such  that  it  may  in  bulk  exceed  that  of  the  ovarian  tumor. 
This  is  more  likely  to  occur  in  malignant  growths  and  in  papillary 
ovarian  cysts.  This  will  be  referred  to  again  while  discussing  diag- 
nosis and  treatment. 

There  are  many  local  and  constitutional  conditions  which  may 
be  found  accompanying  ovarian  tumors,  but  those  complications 
which  can  be  rationally  considered  as  resulting  from  the  affection  of 
the  ovary  have  been  mentioned. 


CHAPTER  XXVII. 

CYSTIC   TUMORS    OF    THE    OVARIES — SYMPTOMATOLOGY    AND    PHYSICAL 

SIGNS. 

The  most  peculiar  feature  in  the  clinical  history  of  this  variety 
of  ovarian  tumor  is  the  fact  that  subjective  symptoms  are  often  ab- 
sent. Cases  are  sometimes  seen  in  which  the  patient  is  unconscious 
of  anything  being  wrong  until  the  tumor  becomes  noticeable  by 
the  increased  size  of  the  abdomen.  It  is  equally  strange  that  the 
tumor  is  often  unobserved  by  the  patient  until  it  has  attained  a  con- 
siderable size.  But,  while  cases  occur  without  noticeable  symptoms, 
the  majority  of  patients  suffer  from  some  pain  and  discomfort,  and 
at  the  same  time  there  is  more  or  less  derangement  of  tlie  function 
of  the  ovaries,  and  occasionally  some  disturbance  of  neighboring 
organs.  The  symptoms  differ  in  the  different  stages  of  the  growth 
of  the  tumor.  I  will,  therefore,  take  up  the  three  stages  in  order. 
In  the  first  stage,  while  the  tumor  still  occupies  the  pelvic  cavity, 
the  patient  may  have  a  feeling  of  fullness  in  the  pelvis,  and  pos- 
sibly some  pelvic  tenesmus  on  standing  or  walking;  pain  is  also 
present  in  the  affected  side.  The  severity  of  the  pain  differs  great- 
ly in  different  cases.  In  some  it  is  only  sufficient  to  attract  the 
attention  of  the  patient  at  times,  but  is  not  acute  enough  to  pre- 
vent her  from  performing  her  ordinary  duties.  In  others  it  is 
quite  severe,  and  accompanied  with  well-detined  tenderness,  dis- 
abling the  patient  to  some  extent.  These  symptoms  may  or  may 
not  be  continuous.  The  pain  may  be  at  times  very  slight  for  days 
or  weeks,  then  increase,  and  again  subside,  and  yet  at  no  time  be 
sufficiently  marked  to  cause  the  sufferer  to  seek  advice,  and  its  ex- 
istence is  only  brought  out  by  interrogation  at  a  more  advanced 
stage  of  the  affection.  When  the  pain  is  acute  and  sufficient  to  dis- 
able the  patient,  there  is  usually  some  local  inflammation  to  account 
for  it.  When  such  is  the  case,  there  is  ordinarily  some  constitutional 
disturbance  indicative  of  tlie  local  affection.     In  quite  a  number  of 


CYSTIC  TUMORS   OF  TQE   OVARIES.  489 

cases  there  is  pain  for  a  few  days  at  or  just  before  the  menstrual 
period,  or  it  may  be  midway  between  the  periods. 

The  pain  is  in  the  affected  ovary,  and  is  often  of  that  cliaracter 
which  is  called  ovarian.  It  has  been  supposed  that  this  kind  of  in- 
termittent pain  is  due  to  ovulation,  occurring  in  the  morbid  ovary. 
When  the  pain  occurs  in  the  intra-menstrual  period,  it  is  presumed 
to  be  caused  by  some  trouble  during  the  maturation  of  the  ovule ; 
and,  when  it  comes  on  about  the  menstrual  period,  it  is  due  to  the 
process  of  rupture  of  the  Graafian  vesicle.  Menstruation  is  fre- 
quently deranged,  but  not  always.  While  one  ovary  is  affected, 
the  other  may  be  normal,  and,  so  far  as  the  ovaries  influence  men- 
stniation,  there  is  no  change,  and  the  uterine  function  goes  on  in 
the  usual  way.  This  is  sometimes  the  case  when  both  ovaries  are 
affected.  It  would  appear  that,  while  a  part  of  the  ovaries  is  mor- 
bid, there  still  remains  enough  that  is  normal  to  perform  the  func- 
tion and  maintain  the  ovarian  influence  upon  menstruation.  It 
frequently  happens,  however,  that  menstruation  is  deranged  dur- 
ing the  existence  of  ovarian  tumors.  As  already  stated,  there  may 
be  pain  at  the  menstrual  period,  which  is  easily  mistaken  for  dys- 
menorrhcea.  Irregularity  or  suppression  of  the  menses  is,  I  believe, 
the  most  common  derangement.  Profuse  and  too  frequent  men- 
struation occasionally  occurs,  but  either  of  these  derangements  may 
be  due  to  some  constitutional  condition  or  some  uterine  affection, 
which  may  accompany  the  ovarian  tumor.  When  the  ovarian  tumor 
attains  considerable  size,  and  is  yet  not  large  enough  to  rise  out  of 
the  pelvis,  it  may  cause  displacement  of  the  uterus  or  bladder,  and 
give  rise  to  symptoms  peculiar  to  this  displacement.  It  is  not  often 
that  these  cause  suflacient  suffering  to  lead  the  patient  to  seek  relief 
at  the  hands  of  the  gynecologist.  When  the  left  ovary  is  the  sub- 
ject of  the  morbid  growth,  there  is,  in  some  cases,  slight  obstruction 
of  the  rectum,  which  causes  disturbance  in  the  action  of  the  bowels. 

The  important  fact  still  remains  that,  in  the  first  stage  of  cystic 
tumors  of  the  ovaries  that  are  uncomplicated,  the  symptoms  are  often 
so  mild  that  the  patient  may  not  come  under  the  care  of  the  medical 
attendant,  and,  if  she  does,  the  symptoms  do  not  afford  any  reliable 
guide  to  the  nature  of  the  affection. 

In  short,  there  is  nothing  diagnostic  in  the  symptomatology  of 
this  stage  of  ovarian  tumors. 

In  the  second  stage,  an  enlargement  of  the  abdomen  is  noticed 
sooner  or  later  by  the  patient.  If  the  pedicle  is  short,  the  enlarge- 
ment may  be  on  one  side ;  usually  it  is  central,  or  nearly  so,  when 
flrst  noticed.     Here,  again,  there  are  no  other  very  well-marked 


490  DISEASES  OF   WOMEN. 

symptoms.  As  tlie  tumor  increases,  the  weight  and  pressure  cause 
discomfort.  This  is  hkely  to  be  felt  earlier  in  those  who  have  not 
borne  children  than  in  those  who  liave.  In  such  patients  the  alj- 
dominal  muscles  do  not  yield  so  readily  to  accommodate  the  tumor. 
Slight  pains  recurring  at  intervals  and  tenderness  are  common  symp- 
toms, and  are  usually  due  to  tension  of  the  cystic  walls  from  increase 
of  the  contents.  When  such  pains  occur,  the  tension  of  the  cyst  is 
marked,  and  the  pain  subsides  when  the  cyst  becomes  liaccid.  If 
inflammation  of  the  cyst  or  portions  of  the  peritonaeum  occurs,  there 
are,  in  addition  to  pain  and  tenderness,  some  constitutional  symp- 
toms, such  as  fever,  rigors,  and,  if  the  inflannnation  is  extensive, 
deranged  digestion,  loss  of  flesh,  and  hectic  may  follow.  Thes3 
symptoms  are  relied  upon  as  indicating  inflammation,  which  will 
produce  adhesions,  especially  if  the  peritonceum  is  involved ;  but 
it  should  be  borne  in  mind  that  quite  extensive  adhesions  may  take 
place  without  their  having  been  at  any  time  well  defined  symptoms 
of  circumscribed  peritonitis.  Ortlinarily,  these  are  all  the  symptoms 
manifested  in  the  second  stage. 

In  the  third  stage,  when  the  tumor  begins  to  make  strong  press- 
ure upon  the  different  viscera,  another  class  of  symptoms  appears. 
These  were  hinted  at  while  discussing  the  growth  of  ovarian  tumors. 
Deranged  digestion  and  impaired  micturition,  diflicult  breathing, 
distressing  weight,  and  a  dragging  on  the  abdominal  nmscles,  to- 
gether with  pain  and  tenderness,  may  all  supervene.  Some  of  the 
symptoms  which  characterize  the  fli'st  stage,  and  disappear  in  the 
second,  often  recur  in  the  third.  Pressure  on  the  bladder  may  cause 
frequent  urination,  and  the  bowels  may  become  obstinately  consti- 
pated. Paroxysms  of  pain  in  the  limbs  and  abdomen  may  be  very 
severe,  caused  by  obstructed  circulation.  From  the  same  cause  ef- 
fusion of  fluid  into  the  abdominal  cavity  and  oedema  of  the  legs  may 
occur. 

The  patient  becomes  emaciated,  weak,  and  sometimes  hectic,  but 
not,  as  a  rule,  cachectic  in  the  benign  forms  of  ovarian  tumore. 

Physical  Signs. — The  physical  examination  of  ovarian  tumors 
is  made  by  the  means  generally  employed,  and  fully  described  in 
the  first  chapter  of  this  work.  They  are  inspection,  vaginal  touch, 
palpation,  percussion,  auscultation,  measurement,  exploration  by  as- 
l^iration,  microscopical  and  chemical  examination  of  fluid  obtained  by 
aspiration,  and,  finally,  laparotomy.  The  evidence  obtained  by  phys- 
ical exploration  differs  in  each  stage  of  the  growth  of  ovarian  tumors. 
In  the  first  stage,  the  bimanual  examination  of  the  pelvic  contents 
is  all  that  is  necessary,  this  giving  all  the  information  whicli  can  be 


CYSTIC  TUMORS  OF  THE   OVARIES.  491 

obtained,  except  in  obscure  cases,  where  aspiration  may  be  advisable. 
Sometimes  it  may  be  necessary  to  pass  the  sound  into  the  uterus  to 
confirm  or  correct  the  impressions  obtained  by  the  touch.  Occa- 
sionally, also,  when  the  parts  are  tender  and  resisting,  it  is  necessary 
to  give  an  anaesthetic  in  order  to  make  a  satisfactory  examination. 
The  method  of  searching  for  small  ovarian  cysts  in  the  pelvis  is  the 
same  as  tljat  recommended  in  prolapsus  of  the  ovary,  and  described 
in  a  previous  chapter.  Where  the  tumor  has  attained  any  consider- 
able size,  the  bimanual  touch  gives  the  most  satisfactory  evidence. 
The  tumor,  caught  between  the  fingers  of  the  two  hands,  can  be 
outlined,  and  its  consistence  ascertained  with  a  tolerable  degree  of 
accuracy. 

In  the  early  stage  the  cyst  is  usually  found  on  one  side  of  the 
pelvis,  or  else  in  the  sac  of  Douglas,  exactly  behind  the  uterus,  or 
a  little  inclined  to  one  side.  It  is  usually  soft  and  slightly  yielding 
to  the  touch,  sometimes  globular  and  smooth  of  surface,  or  else 
globular  in  the  main,  with  some  irregular  projections.  These  irregu- 
larities are  due  to  the  presence  of  small  cysts  and  the  portions  of  the 
ovary  that  remain  normal. 

The  physical  signs  obtained  by  this  examination  determine  the 
fact  that  there  is  a  neoplasm,  and  that  it  is  possibly  cystic ;  but  there 
is  no  direct,  positive  evidence  regarding  the  structure  of  the  tumor, 
nor  that  it  is  ovarian.  In  other  words,  the  physical  signs  are  not 
diagnostic — i.  e.,  direct  and  positive.  It  is  necessary,  on  this  account, 
to  employ  the  method  of  diagnosis  by  exclusion. 

Diagnosis. — There  are  many  affections  which  may  present  symp- 
toms and  signs  remotely  resembling  cystic  tumors  of  the  ovary. 
Those  which  most  nearly  approach  them  in  character  are.  dilatation 
of  the  Fallopian  tube  from  hydrosalpinx  or  pyosalpinx,  parovarian 
cysts  when  small,  extra-uterine  pregnancy,  pregnancy  in  a  bicornute 
uterus,  subperitoneal  fibroids  of  the  uterus,  fibroid  tumor  of  the 
ovary,  and  tumors  of  the  second  class,  which  include  the  cystic  and 
solid  malignant  growths,  and  in  a  less  degree  pelvic  hematocele, 
pelvic  peritonitis,  and  cellulitis. 

Fecal  accumulations  in  the  upper  part  of  the  rectum,  and  back- 
ward dislocations  of  the  uterus  have  also  been  mentioned  as  simulat- 
ing ovarian  tumors,  but  these  can  be  so  easily  differentiated  that  they 
need  only  to  be  named.  Dilatation  of  the  Fallopian  tube  may  be 
distinguished  from  a  cystic  ovary  by  its  oblong  shape,  and  some- 
times, when  the  tube  is  low  down  in  the  sac  of  Douglas,  the  normal 
ovary  can  be  felt  above  the  tube  by  the  bimanual  touch.  In  case 
the  dilatation  of  the  tube  is  due  to  pyosalpinx,  the  history  will  tell 


492  DISEASES   OF   WOMEN. 

of  a  previous  inflammation,  and  the  constitutional  symptoms  are  usu- 
ally more  marked.  Should  it  be  necessary  to  make  an  immediate 
diagnosis,  the  tumor  may  be  aspirated,  and  the  characteristic  epithe- 
lium of  the  tube,  if  found  by  the  microscope,  will  decide  the  question. 
It  is  safer  and  surer  to  wait  and  watch  the  progress  of  the  case.  In 
time  the  ovarian  tumors  will  grow  and  rise  out  of  the  pelvis,  while 
in  case  of  a  dilated  tube  there  will  not  be  any  great  increase  in  size, 
but  there  will  be  more  local  and  constitutional  disturbance.  This 
difference  in  the  progress  of  the  two  affections  is  the  most  reliable 
means  of  differentiation.  Parovarian  cvsts  can  not  be  distintniished 
from  ovarian  when  they  are  small,  unless  the  ovary  can  be  separated 
from  the  cyst,  and  ascertained  to  be  normal.  Fortunately,  it  is  not 
of  great  importance  to  distinguish  the  one  form  of  cyst  from  the 
other  in  the  first  stage  of  their  growth.  Extra-uterine  ])regnancy 
presents  physical  signs  which  can  not  always  be  distinguished  from 
those  of  ovarian  tumors,  and  in  both  there  is  a  gradual  increase  in 
size,  so  that  neither  the  physical  signs  nor  the  progress  of  the  case 
are  reliable  aids  in  diagnosis.  The  general  signs  and  symptoms  are 
usually  sufficient  to  decide.  In  cases  of  doubt,  the  electrical  treat- 
ment which  arrests  the  progress  of  tlie  gestation  shc>uld  be  tried. 
Pregnancy  in  the  uterus  bicomis  may  be  detected  by  finding  the 
other  hora  of  the  uterus,  and  perhaps  the  ovaries  may  be  found  nor- 
mal. These  conditions  are  rare,  and  will  not  frequently  come  up  as 
questions  of  diagnosis  in  ovarian  affections. 

Small,  subperitoneal  fibroids  of  the  uterus  differ  from  ovarian 
cysts  in  being  firm  to  the  touch,  and  generally  accompanied  with 
enlargement  of  the  uterus  and  menorrhagia.  They  are,  when  small, 
usually  united  closely  to  the  uterus.  An  ovarian  cyst  is  likely  to 
be  mistaken  for  a  fibroid  of  the  uterus  when  it  is  very  tense  and 
adherent  to  the  uterus  by  inflammatory  adhesions.  Here,  again, 
time  will  determine,  because  the  ovarian  will  grow  faster  than  the 
uterine  tumor,  and  will  show  its  characteristics  more  clearly  the 
larger  it  grows.  A  fibroid  tumor  of  the  ovary  can  not  be  distin- 
guished from  a  tense  ovarian  cyst  or  a  fibro-cyst  of  the  ovary  in  all 
cases  by  physical  signs,  but  the  history  will  help  materially  in  mak- 
ing a  diagnosis,  and,  when  the  fibroid  becomes  large  enough  to  rise 
out  of  the  pelvis,  its  solid  character  will  be  easily  made  out. 

Xeither  can  a  fibro-cyst  of  the  ovary  be  distinguished  from  a 
multiple  cystic  tumor  in  which  the  cyst-walls  are  very  thick.  But 
the  diagnosis  of  the  exact  composition  of  such  tumors  is  not  of  any 
practical  importance  in  relation  to  treatment. 

From  what  has  been  said  it  will  be  seen  that  the  question  to  be 


OYSTIO   TUMORS   OF   THE   OVARIES.  493 

decided  is,  Whether  the  tumor  found  in  the  pelvis  is  ovarian  or  not ; 
and,  when  that  is  settled,  the  next  question  which  arises  is,  What  is 
tlie  nature  of  the  tumor?  If  it  can  be  determined  that  the  tumor 
belongs  to  the  first  class  of  ovarian  neoplasms,  that  will  suffice  for 
such  cases.  It  is  otherwise  in  tumors  of  the  second  class,  because 
in  malignant  affections  it  is  important  to  make  a  diagnosis  early.  If 
the  tumor  is  of  the  first  class,  no  harm  can  come  from  waiting,  while, 
if  it  is  of  the  second,  surgical  interference  may  be  necessary  while 
the  tumor  is  yet  small.  The  physical  signs  of  malignant  ovarian 
tumors  will  be  spolcen  of  in  another  chapter,  but  I  may  briefly  state 
here  that  the  density  and  irregularity  of  outline,  so  commonly  found 
in  malignant  disease  elsewhere,  are  wanting  in  the  cystic  tumors  of 
the  ovary.  The  constitutional  disturbances  are  usually  developed 
early  in  malignant  diseases,  while  it  is  otherwise  in  the  benign 
forms. 

Pelvic  hematocele,  pelvic  peritonitis  and  cellulitis  may,  after  the 
acute  stage  of  these  aiiections  has  subsided,  present  certain  physical 
signs,  which  may  lead  one  to  suspect  an  ovarian  cystic  tumor.  But 
the  history  of  such  aifeetions  will  put  the  diagnostician  on  his  guard, 
so  that  time  may  be  given  to  see  whether  the  tumor  which  has  been 
discovered  grows,  as  it  will  do  if  it  is  a  cystic  ovary,  except  in  rare 
cases  of  an  ovarian  cyst  arrested  in  its  growth  by  inflammation  or 
other  causes. 

Physical  Signs  in  the  Second  Stage. — By  the  time  that  such  a 
tumor  has  escaped  from  the  pelvic  to  the  abdominal  ca\dty,  and  at-, 
tracts  attention  by  its  presence  there,  it  wdll  have  attained  a  size 
equal  to  that  of  the  gravid  uterus  at  the  fifth  month  of  gestation. 
In  patients  of  spare  habit  it  might  be  noticed  sooner,  but  quite  as 
often  it  escapes  notice  until  a  much  later  period.  The  physical  signs 
which  are  of  most  value  to  the  diagnostician  in  the  second  stage  are 
enlargement  of  the  abdomen,  especially  of  the  lower  poii;ion ;  some 
irregularity  in  the  form  of  the  abdomen,  one  side  being  larger  than 
the  other,  and  the  lower  being  larger  proportionately  than  the  upper ; 
the  tumor  is  Avell  defined  and  movable  in  the  cavity  of  the  abdo- 
men, most  freely  from  side  to  side.  It  is  elastic  and  fluctuating,  the 
fluctuation  extending  through  the  whole  tumor  if  a  mono-cyst,  while, 
if  a  multiple  cystic  tumor,  the  fluctuation  may  be  limited  to  sections 
of  the  tumor.  The  tumor  does  not  change  its  form  to  any  extent 
when  the  position  of  the  patient  is  changed,  neither  does  the  form 
of  the  abdomen  change.  It  is  attached  to  the  pelvic  organs,  and, 
if  drawn  upward,  will  drag  the  broad  ligament  up  with  it.  The 
gross  and  mici'oscopic  appearances  and  chemical  composition  of  the 


4'J4  DISEASES   OF   WOMEN. 

fluid  ol)tainc'd  by  aspiration  are  also  to  be  regarded.  The  contents 
of  the  cyst  are  characteristic,  to  some  extent,  of  the  affection,  and 
Anally  tlie  presence  and  appearance  of  the  cyst  as  seen  after  open- 
in<^  the  abdomen.  The  signs  are  very  few,  and  neither  of  them 
alone  is  diagnostic.  In  fact,  each  of  them  may  be  found  in  other 
conditions  than  cystic  ovarian  tumors ;  hence  arises  the  difficulty  of 
making  a  diagnosis.  The  signs  and  the  means  of  detecting  them 
may  now  be  discussed. 

By  inspection  the  increased  size  of  the  abdomen  is  detected.  In 
the  second  stage  this  is  most  marked  at  the  lower  portion.  The 
increase  in  size  may  be  uniform,  the  two  sides  being  alike,  or  one 
side  may  be  larger  than  the  other,  and  in  some  cases  there  is  an 
irregularity  of  outline  of  the  tumor,  which  gives  a  nodular  appear- 
ance upon  inspection,  and  Avhich  is  also  apparent  to  the  touch.  A 
tumor,  large  enough  to  be  noticeable  in  the  abdomen,  is  usually  in 
the  center,  and,  when  it  is  eccentric,  it  is  because  of  adhesions,  as  a 
rule. 

The  irregular  outline  or  nodular  appearance  is  indicative  of  a 
multiple  or  multilocular  tumor.  By  palpation  the  tumor  can  usually 
be  distinctly  outlined.  This  is  always  the  case,  unless  the  tumor  is 
very  flaccid,  and  there  is  much  fat  in  the  abdominal  walls,  or  the 
bowels  are  distended,  but  it  is  rare  that  these  two  conditions  are 
found  together.  By  grasping  the  tumor  in  both  hands,  it  can  be 
moved  from  side  to  side  in  the  abdominal  cavity.  It  can  l)e  felt 
sliding  about  under  the  abdominal  walls.  When  there  are  extensive 
adhesions,  this  valuable  sign,  mobility,  is  wanting.  By  inspection 
the  mobility  may  be  detected  by  causing  the  patient  to  take  deep 
inspirations  and  expirations,  which  -w-ill  cause  the  tumor  to  move  up 
and  down  beneath  the  abdominal  walls.  This  movement  will  be 
absent  if  there  are  adhesions. 

The  vaginal  touch  may  detect  a  portion  of  the  tumor  in  the  pel- 
vis, or  may  show  that  the  round  globular  mass  rests  on  the  pelvic 
brim.  The  uterus  can  be  made  out,  in  a  large  number  of  cases,  as 
normal,  and  not  directly  connected  with  the  tumor,  although  it  may 
be  displaced.  Beyond  this,  the  touch  per  vaginam  only  gives  valua- 
ble negative  evidence.  Palpation  also  shows  that  the  tumor  is  clearly 
outlined  and  easily  distinguished  from  the  neighboring  organs  in 
some  cases.  When  the  cyst  is  tense,  the  tumor  can  be  easily  out- 
lined, but  when  flaccid,  as  often  occurs,  it  is  not  by  any  means  easy 
to  map  out  its  boundaries. 

Percussion  assists  in  outlining  the  tumor  when  it  is  not  clearly 
defined  to  the  touch.     The  flatness  on  percussion  over  the  tumor 


CYSTIO  TUMORS  OF  THE  OVARIES. 


495 


contrasted  with  the  tympanitic  resonance  of  the  intestines,  will  indi- 
cate its  size  and  position. 

The  consistence  can  be  determined  by  palpation,  whether  solid 
and  very  hard,  solid  and  soft,  or  fluid  and  fluctuating.  Fluctuation, 
as  a  sign  of  encysted  fluid,  may  be  obtained  in  several  ways.  If  the 
tumor  is  a  monocyst  and  is  large  enough  to  touch  the  walls  of  the 
abdomen  on  both  sides,  diametrical  fluctuation  can  be  obtained  by 
placing  the  fingers  upon  one  side,  and  percussing  diametrically  oj)- 
posite.  The  fluctuating  wave  will  be  easily  found  if  the  contents 
of  the  cyst  are  markedly  fluid.  If  the  tumor  is  divided  into  several 
sacs,  fluctuation  can  only  be  obtained  by  j)alpating  sections  of  it. 
Resting  the  fingers  of  one  hand  at  one  point  on  the  abdomen,  and 
percussing  at  another  point  a  little  distance  from  that  at  which  the 
fingers  rest,  a  surface  wave  will  be  produced.  In  case  the  fluid  is 
semi-solid,  and  does  not  give  the  clear  wave  on  percussion,  fluctua- 
tion may  be  produced  by  placing  the  fingers  of  both  hands  upon  the 
tumor  some  distance  apart ;  then,  by  making  pressure  with  the  fin- 


FiGS.  196,  197. — Area  of  dullness  in  ovarian  tumor  and  in  ascites  (Barnes). 

gers  of  one  hand,  the  contents  of  the  cyst  will  be  pressed  under  the 
fingers  of  the  other.  This  is  fluctuation  by  displacement,  not  by  the 
wave  produced  by  pressure. 

The  fact  that  fluctuation  is  limited  and  does  not  extend  through- 
out the  whole  abdominal  cavity  is  most  valuable  evidence  that  the 
fluid  is  encysted.  Further  evidence  of  this  is  also  obtained  by  an- 
other sign,  that  is,  the  tumor  does  not  change  its  form  when  the 
position  of  the  patient  is  changed.     By  turning  the  patient  first  on 


496  DISEASES  OF   WOMEN". 

one  side  and  then  on  the  other,  it  will  be  observed  that  while  the 
tumor  may  gravitate  to  the  lower  side  it  does  not  change  its  form. 

In  the  second  stage  it  can  be  ascertained  that  tlie  tumor  ifi  at- 
tached to  tiie  l)i-t>ad  ligament.  This  sign  is  obtained  l>y  passing  the 
finger  of  one  hand  into  the  vagina  and  then  pnsliing  up  the  tumor 
with  the  other.  By  this  means  the  tumor  will  be  observed  to  drag 
upon  the  broad  ligament. 

In  I'egard  to  the  signs  obtained  by  an  examination  of  the  con- 
tents of  the  cyst,  it  may  be  said,  that  it  is  not  often  that  this  need 
be  resorted  to  in  the  second  stage,  but  when  it  is,  the  reader  should 
turn  to  the  descri])tion  of  the  contents  of  ovarian  cysts  for  all  de- 
sired information  on  this  point. 

The  physical  signs  of  ovarian  and  other  abdominal  tumors 
obtained  by  laparotomy  are,  of  course,  peculiar  to  each.  The  de- 
scriptions of  these  appearances  may  help  one  to  recognize  such 
tumors  when  seen  and  felt,  but  much  experience  in  observation  is 
necessary  to  toll  what  a  tumor  is  when  one  sees  it  in  the  abdominal 
cavity.  The  ambitious  and  rash  may  open  the  abdomen  to  make  a 
diagnosis,  and  be  unable  to  recognize  that  which  they  find.  "While 
I  clearly  appreciate  the  value  of  laparotomy  as  a  means  of  diagnosis 
in  obscure  cases,  I  am  as  fully  aware  that  it  should  only  be  under- 
taken by  one  possessing  comiDrehensive  knowledge  gained  by  exten- 
sive experience. 

There  are  certain  other  affections  and  conditions  which  resemble 
to  some  extent  ovarian  tumors  in  the  second  stage.  The  chief  of 
these  are  pregnancy,  normal  and  pathological,  neoplasms  of  the 
uterus,  such  as  fibroids  and  fibro-cysts;  distended  bladder;  fecal 
impaction ;  encysted  fluid  in  the  peritoneal  cavity,  e.  g.,  in  tubercu- 
lar peritonitis  ;  cysts  of  the  kidney,  liver,  or  spleen  ;  enlargement 
and  displacement  of  the  spleen,  kidney,  oi-  liver;  cancerous  disease 
of  any  of  the  abdominal  organs,  omentum  or  abdominal  glands ;  and 
parovarian  cysts. 

Pregnancy,  in  its  normal  state,  differs  greatly  from  ovarian  tu- 
mors in  all  respects  but  the  fact  that  both  gravid  uterus  and  the 
tumor  occupy  the  abdominal  cavity,  still  a  number  of  cases  have 
been  reported  in  which  an  error  in  diagnosis  was  made,  and  ovari- 
otomy undertaken  when  the  case  was  one  of  pregnancy.  In  sev- 
eral of  these  cases  the  trocar  has  been  thrust  into  the  uterus,  the 
operator  believing  that  he  was  tapping  an  ovarian  cyst.  At  the 
present  time  such  a  mistake  can  only  be  made  through  want  of 
knowledge  or  want  of  attention.  One  might,  in  trying  to  make  a 
diagnosis,  mistake  the  pregnant  uterus  for  an  ovarian  cyst,  but  upon 


CYSTIC   TUMORS   OF   THE   OVARIES.  497 

opening  tlic  alxloniun  one  having  knowledge  enough  to  warrant 
him  in  undertaking  ovariotomy  ought  to  be  able  to  tell  the  one  from 
the  other  by  sight. 

When  there  is  any  doubt,  it  is  far  better  to  wait  until  tlie  end 
of  the  time  of  gestation.  This  can  always  be  done.  There  is  no 
good  reason  for  removing  an  ovarian  cyst  until  it  is  as  large  or 
larger  than  the  uterus  at  full  term  of  gestation  in  doubtful  cases. 
While  I  believe  in  removing  ovarian  tumors  in  the  second  stage 
of  their  development  when  the  diagnosis  is  clear,  in  case  there  is 
room  for  doubt,  whether  the  case  is  one  of  ovarian  cyst  or  of  preg- 
nancy, time  will  decide,  and  there  is  no  valid  argument  against  wait- 
ing. 

The  fact  is  that  those  who  are  the  least  capable  of  making  a 
diagnosis  are  the  most  inclined  to  operate  early,  and  this  I  presume 
accounts  for  the  mistakes  recorded. 

I  need  not  give  the  differential  diagnosis  between  ovarian  tumors 
and  normal  pi'egnancy  ;  the  symptoms  and  signs  of  the  former  have 
been  given,  and  those  of  the  latter  can  be  found  in  any  text-book  on 
obstetrics,  if  not  already  familiar  to  the  reader,  and  they  are  so  very 
different  that  by  contrast  the  diagnosis  can  be  made. 

Extra-uterine  pregnancy  usually  comes  up  for  diagnosis  in  con- 
nection with  the  first  stage  in  the  growth  of  ovarian  tumors,  as  has 
already  been  stated.  It  is  only  the  abdominal  variety  which  in  any 
way  resembles  ovarian  tumors  in  the  second  stage.  The  signs  of  a 
living  child  in  the  abdomen  are  so  perfectly  diagnostic  that  they  can 
hardly  be  mistaken.  In  case  the  child  is  dead,  more  difficulty  might 
be  experienced  in  making  a  diagnosis.  The  history  of  the  case  and 
hallottement  or  the  ability  to  move  the  dead  child  in  the  sac,  will 
usually  suffice  to  settle  the  question. 

Rupture  of  an  ovarian  cyst  and  the  extensive  adhesions  which 
follow,  most  closely  resemble  ventral  pregnancy  after  the  death  of 
the  child,  both  in  history  and  in  physical  signs,  and  1  can  under- 
stand that  it  might  be  impossible  to  discover  the  exact  nature  of  the 
trouble  without  the  aid  of  laparotomy.  Fortunately,  under  these 
circumstances  it  would  be  perfectly  right  to  employ  this  method  of 
making  tlie  diagnosis,  because  it  is  part  of  the  appropriate  treat- 
ment in  either  case. 

In  the  cases  of  abdominal  pregnancy  that  I  have  seen  the  diag- 
nosis was  very  easy ;  so  much  so  that  no  one  with  any  experience 
could  have  made  the  mistake  of  suspecting  ovarian  tumor. 

Uterine  Fibroids  and  Fibro-Cysts,  when  large,  present  some  of 
the  evidences  of  ovarian  tumors.  The  position  of  the  tumor  in  the 
S3 


498  DISEASES  OF  WOMEN. 

abdomen,  and  its  shape  and  mobility,  are  the  same  as  those  of  some 
ovarian  tumors,  and  these  are  the  only  resemblances. 

In  fibroids,  the  uterus  is  enlarged  as  shown  by  the  touch  and 
sound.  The  tumor  is  solid  and  is  intimately  eomiected  with  the 
uterus,  in  fact  forms  a  part  of  it.  In  the  majority  of  cases  the  cav- 
ity of  the  uterus  can  be  probed,  and  will  be  found  enlarged  in  ease 
the  tumor  is  uterine,  while  it  will  not  be  if  the  tumor  is  ovarian. 

Distended  Bladder  has  been  mistaken  for  a  cyst  of  the  ovary, 
but  only  at  a  first  examination  or  by  one  not  used  to  such  cases. 
When  the  bladder  is  overdistended  there  is  incontinence,  usually 
the  urine  coming  away  constantly,  or  in  spurts  when  the  patient 
moves.  This  leads  the  medical  attendant  to  suppose  that  the  blad- 
der must  be  empty  and  that  the  tumor  is  an  ovarian  cyst,  but  the 
catheter  readily  settles  the  question,  and  it  should  always  be  used  in 
cases  with  such  histories. 

Fecal  Impaction  has  always  been  mentioned  as  one  of  the  condi- 
tions whicli  might  be  mistaken  for  an  ovarian  tumor,  but  I  have  not 
considered  such  a  thing  possible.  The  irregular  form  and  solid 
character  of  the  fecal  mass  differs  in  every  respect  from  ovarian 
tumors  of  all  the  benign  variet}'. 

Encysted  Dropsy  of  the  Peritonseum. — This  is  an  extremely  rare 
affection  and  occurs  in  the  progress  of  tubercular  disease  as  a  rule, 
and  follows  an  attack  of  peritonitis.  The  physical  signs  differ,  in 
that  the  fluctuation  is  not  so  general  as  in  ovarian  cyst,  and  the  fixa- 
tion is  complete.  The  surface  of  the  abdomen  is  not  so  prominent 
as  in  case  of  a  cyst,  but  often  has  irregular  depressions,  as  well  as 
elevations,  and  the  veins  are  not  prominent. 

The  general  health  is  greatly  reduced  early  in  the  progress  of 
the  disease  ;  nutrition  is  markedly  impaired,  and  there  is  often  sep- 
ticaemia in  case  that  there  is  pus  encysted. 

The  vaginal  examination  is  often  quite  sufficient  to  settle  the 
diagnosis,  by  showing  that  the  pelvic  organs  are  normal  and  can  be 
outlined  and  separated  from  the  mass  in  the  abdomen.  When  this 
can  be  accomplished,  ovarian  disease  is  at  once  excluded. 

Enlargement  and  Cysts  of  the  Liver,  Spleen,  and  Kidneys. — In  all 
of  these  the  diagnosis,  so  far  as  the  exclusion  of  ovarian  disease,  can 
be  easily  made  if  the  cases  are  seen  early,  or  a  correct  history  can  be 
obtained.  It  is  found  thai|  in  them  all  the  enlargement  begins 
above  and  on  one  side,  and,  as  a  rule,  is  fixed  there  from  the  begin- 
ning, and  the  pelvic  organs  can  be  separated  from  the  tumor  above, 
and  proved  to  have  no  connection  with  the  morbid  growth,  and  to 
be  normal.     These  two  diagnostic  facts  will  suffice  in  most  cases  to 


CYSTIC  TUMORS  OF  THE  OVARIES.  499 

settle  the  question,  but  additional  evidence  can  be  obtained  from  the 
general  history  of  the  growth  and  its  effects  upon  the  general 
health,  also  the  composition  of  the  fluid  in  cysts,  which  should  be 
obtained  by  aspiration  in  doubtful  cases. 

In  regard  to  the  differential  diagnosis  in  cancer  of  the  pelvic  and 
abdominal  organs,  this  will  be  discussed  in  connection  with  these 
affections,  and  hence  is  omitted  here. 

Parovarian  Cysts,  or  serous  cysts  of  the  broad  ligament,  as  they  are 
called,  are  not  very  easily  recognized  at  all  times.  Fortunately  it 
would  be  no  very  great  mistake  to  remove  one  of  these  cysts  suppos- 
ing that  it  was  an  ovarian  cyst.  They  are  very  rare  as  compared 
with  ovarian  cysts,  they  grow  slowly,  and  occur  mostly  in  young  per- 
sons. The  general  health  does  not  suffer,  as  a  rule.  The  physical  signs 
differ  in  no  way  from  those  of  the  ovarian  monocyst,  except  that 
the  fluctuation  is  more  distinct  and  the  fluid  differs,  being  clear  like 
water  and  without  albumen.  Tapping,  or  rather  exploratory  aspira- 
tion, is  the  means  to  be  employed  to  settle  the  diagnosis,  and  should 
be  practiced  when  there  is  a  doubt. 

Affectons  which  resemble  Ovarian  Neoplasms  in  the  Third  Stage. 
— There  are  only  a  few  affections  which  resemble  ovarian  cysts  in 
the  third  stage.  These  are  ascites,  uterine  fibro-cysts,  and  very  large 
uterine  fibromata. 

The  first  mentioned,  ascites,  is  the  most  likely  to  be  mistaken  for 
ovarian  cyst.  The  chief  points  of  difference  in  history  are,  that  as- 
cites is,  as  a  rule,  preceded  by  some  acute  disease  or  general  ill- 
health,  suggestive  of  some  chronic  disease  of  the  liver,  heart,  or  kid- 
neys. There  is  anasarca  also  in  most  cases  of  ascites,  and  the  pa- 
tient is  generally  ansemic  early  in  the  progress  of  the  disease.  The 
enlargement  of  the  abdomen  comes  on  rather  suddenly,  and  is  not 
confined  to  its  lower  part ;  that  is,  it  is  not  circumscribed.  The  ex- 
pression of  the  face,  while  showing  anaemia  in  ascites,  is  not  anxious, 
as  it  usually  is  in  ovarian  cyst.  The  history  of  ovarian  cyst  in 
growth  and  general  constitutional  symptoms  is  almost  the  reverse  of 
ascites. 

The  physical  signs  of  ascites  difffer  from  ovarian  cyst,  chiefly  in 
that  the  fluid  in  ascites  changes  its  position  with  every  change  in  the 
position  of  the  patient.  When  the  patient  is  placed  upon  the  back, 
the  abdomen  is  symmetrical  and  flat ;  in  the  erect  position,  the  lower 
portion  bulges  from  the  gravitation  of  the  fluid,  and  the  same 
change  in  the  position  of  the  fluid  occurs  when  the  patient  is  turned 
toward  either  side.  With  these  changes  in  the  position  of  the  fluid, 
there  is  a  change  in  the  resonance  on  percussion.     The  flatness  is 


500  DISEASES  OF   WOMEN. 

found  at  the  mosi  de])ciuleiit  part,  while  the  resonance  is  found  at 
the  up])er. 

In  large  cysts  there  is  dnlhiess  or  flatness  on  percussion  at  all 
points  except  the  flanks,  where  there  is  always  resonance,  except 
when  the  colon  is  distended  with  gas  and  fixed  deep  in  the  side,  so 
that  the  fluid  of  ascites  can  not  gravitate  below  it ;  and  in  ovarian 
cyst  there  may  be  dullness  on  percussion  in  the  side  due  to  fecal  im- 
paction of  the  colon. 

There  is  another  exception  to  the  rule  that  in  ascites  there  is 
always  resonance  at  the  highest  point  of  the  abdomen  whatever  the 
position  of  the  patient  may  be,  and  that  is  when  the  disturbance 
of  the  abdomen  is  extreme,  and  the  mesentery  is  not  long  enough 
to  permit  the  intestines  to  rise  to  the  top  of  the  fluid  while  the  pa- 
tient is  upon  the  back.  There  is  also  a  difference  in  the  fluids,  which 
gives  some  help  in  the  diagnosis  in  case  aspiration  is  practicable,  as 
it  may  be  in  doubtful  cases. 

TJterine  Fibro-Cysts  or  Fibromata  seldom  attain  sufficient  size  to 
resemble  ovarian  cysts,  but  occasionally  they  do  so.  The  fibro-cysts 
of  the  uterus  more  closely  simulate  the  ovarian  cystic  tumors  than 
the  fibromata.  The  difference  in  the  history  and  the  fact  that  the 
uterus  is  involved  in  the  tumor  in  fibro-cyst  and  free  in  the  other 
form,  are  the  chief  points  of  difference.  This  subject  was  discussed 
in  treating  of  the  diagnosis  in  the  second  stage  of  ovarian  tumors, 
and  need  not  be  repeated  in  full  in  this  connection. 

In  the  study  of  the  differential  diagnosis  of  ovarian  neoplasms 
and  other  affections  which  resemble  them,  much  help  may  be  given 
by  contrasting  the  points  of  difference  by  placing  them  together  in 
opposite  columns. 

The  following  arrangement  of  the  facts  in  differential  diagnosis 
I  have  taken  from  Peaslee's  valuable  work  on  ovarian  tumoi-s.  1 
have  ventured  to  make  some  immaterial  changes  of  place  and  position 
of  these  groups  of  facts  in  regard  to  the  general  text,  but  \^ath  some 
sucb  trifling  exceptions  the  whole  is  copied  from  the  original. 


CYSTIC   TDMOIiS   OF   THE   OVARIPLS. 


501 


SUMMARY  OF  FACTS  IN   THE   DIFFERENTIAIi   DIAGNOSIS 
OF  OVARIAN   NEOPLASMS   IN   THE   FIRST   STAGE. 

Differential  Diagnosis  of  Hydrosalpinx  and  Ovarian  Cyst. 

Hydrosalpinx.  Ovarian  (Jyat — Third  Stage. 

Very  rare;  convoluted  at  first;  mono-  Not  rare  nor  convoluted  ;  two  forms. 

cystic. 

Of  very   slow  growth;  probably  eight  Kapid  growth. 

or  ten  years  at  least. 

Health  not  early  impaired;  Much  sooner  impaired. 

Fluid  at  intervals  discharged  per  vagi-  Not  thus  discharged.     It  contains  albu- 

nam.     It  is  generally  clear,  but  va-        men,  but  no  mucus. 

ries ;  contains  mucus. 

Refills  slowly  after  tapping.  Fills  rapidly. 


Differential  Diagnosis  of  Normal  Pregnancy  and  Ovarian  Cyst. 

a    Tialf       Ovarian  Cyst,  second  or  third  stage. 


Normal   Pregnancy  five    and 
months  or  more. 

Enlargement  sudden  and  rapid ;  sym- 
metrical, or  inclined  slightly  to  right 
side. 

Features  natural,  healthy. 

Superficial  veins  of  abdomen  not  en- 
larged. (Edema  of  ankles  not  un- 
common after  seven  months. 

Chest  not  conical. 

Fluctuation  not   very  distinct,   unless 

much  liquor  amnii. 
Menstruation  arrested. 

Vaginal  touch  detects  softening  and  ap- 
parent shortening  of  the  cervix  and 
enlargement  of  the  uterus. 

Ballottement  feels  impulse  of  foetus. 

Fetal  heart-sounds  detected. 

Movements  of  foetus  felt. 

Enlargement  of  mamrafe. 

Umbilical  areola  in  first  pregnancy. 

Has  developed  within  six  to  nine 
months. 

Follicles  around  the  nipple  equally  de- 
veloped in  both  mamma} ;  become 
white  on  stretching  the  skin. 

Exception.  If  foetus  be  dead,  of  course, 
the  movements  and  heart-sounds 
cease. 


Enlargement  gradual ;  asymmetrical  till 
in  the  third  stage. 

Features  emaciated,  anxious. 

Veins  are  enlarged ;  oedema  in  late 
stages,  in  exceptional  cases,  one  to 
two  years  after  commencement. 

Chest  conical,  if  very  great  disten- 
tion. 

Very  distinct,  especially  in  monocysts. 

Not  arrested  till  third  stage  has  com- 
menced. 

No  change  in  these  respects  but  uterus 
is  displaced,  usually  behind  the  cyst. 

No  result.     Very  rarely  is  imitated. 

None. 

None. 

Occurs  in  exceptional  cases  only. 

None. 

Has  developed   within   one    to    three 

years. 
Unequally  developed,    and   remain   of 

the  same  color  as  the  areola. 


502 


DISEASES   OF  WOMEN. 


Differential  Diagnosis  of  Uterine  Fibroma  and  Ovarian  Cyst, 


Uterine  Fibroma. 
Slow  growth. 

Natural  e.\pre8sion,  even  if  large. 
Coinplexion  darker  and  coarser. 
General  liealtli  good.     No  emaciation. 
Abdomen  very  asymmetrical. 
Abdominal  veins  not  enlarged. 
Action  ot  kidneys  normal. 
No  amenorrhoea.     Menorrhagia  often. 
Tender  on  pressm-e ;  more  so   during 

menstruation. 
Elasticity  marked  ;  no  true  fluctuation. 
Surface  lobulated  and  firm. 


Ovarian  Cyst — Third  Stage. 
More  rapid  growth. 
Changed  expression. 
Paler  and  thinner. 
Health  im])aired.     Emaciation. 
More  symmetrical. 
Eidarged  ;  esi)ecially  if  a  polycyst. 
Kidneys  inactive. 
Amenorrhoea. 
No  tenderness. 

Fluctuation  distinct. 

Smooth,  except  polycysts ;  yielding. 


Per  vaginam,  tumor  is  dense  and  firm,  Compressible,      fluctuating,      detached 
and   often   continuous   with   uterus,        from  uterus,  which  is  normal, 
which  is  large  and  heavy. 

Uterus  moves  with  tumor.  Does  not  thus  move. 

Uterine  cavity  elongated.  •  Not  elongated. 

Tapping  gives  negative  results.  Positive  results. 

Exception. — In  case  of  the  subperito- 
neal pedunculated  variety,  size  of  the 
fetal  head,  the  uterine  cavity  may  be 
normal,  and  the  tumor  be  moved 
independently  of  the  uterus. 


Differential  Diagnosis  of  Uterine  Fibro-Cyst  and  Ovarian  Cyst. 

Ovarian  Cyst — Third  Stage. 
Occurs  earlier  than  thirty  years,  as  weU 

as  later. 
More  rapid  and  more  common. 
Expression  characteristic. 
Pale.     Emaciation. 


Uterine  Fibro-  Cyst—  Third  Stage. 

Occurs  after  thirty  years,  almost  al- 
ways. 

Slow  growth  at  first.     Rare. 

Expression  good  till  very  large. 

Complexion  dark  and  injected  (facies 
uterina),  sometimes  florid.  No  ema- 
ciation. 

General  health  for  a  long  time  good. 

Abdominal  veins  not  enlarged. 

Umbilicus  not  prominent. 

No  amenorrhoea.    Menorrhagia  seldom. 

Kidneys  normal. 

Tender  on  ])ressure  at  first. 

Elasticity,  then  evident  fluctuation. 

Surface  lobulated  at  first;  may  remain 
so. 

Cyst-wall  of  livid  hue ;  very  vascular. 


Has  failed  by  end  of  second  stage. 

Enlarged. 

Umbilicus  prominent. 

Amenorrhoea. 

Kidneys  inactive. 

Not  tender. 

Fluctuation  throughout  its  course. 

Not  lobulated,  except  in  polycysts. 

Cyst-wall  of  lighter  color ;  less  vascu- 
lar. 


CYSTIC   TUMORS   OF   THE   OVARIES. 


503 


Per  vaginain,  firm  at  lirst.  Often  con- 
tinuous with  uterus. 

Uterus  moved  witli  tumor,  if  at  all. 

Uterine  cavity  elongated  generally. 

Fluid  yellow,  serous,  witli  little  albu- 
men, or  fibrinous-like  lymph,  and 
spontaneously  coagulable.  But  it 
may  be  dark  brown  or  hferaorrhagic. 

Exception. — If  the  fibro-cyst  be  a  sub- 
peritoneal outgrowth,  the  uterus  may 
be  moved  independently  of  it,  and 
its  cavity  is  not  elongated. 


Fluctuates.  Not  continuous  with  tho 
uterus. 

Indei)cndent  of  tumor. 

Not  elongated. 

Light  in  monoeysts  not  before  tapped  ; 
highly  albuminous;  sometimes  col- 
loid. 


Differential  Diagnosis  of  Cyst  of  the 

Serous  Cyst  of  Broad  Ligament. 

Very  slow  growth;  rare;  always  mono- 
cystic. 

Mostly  in  young  persons. 

Expression  natural ;  not  much  emacia- 
tion. 

General  health  slightly  impaired,  though 
in  third  stage. 

Abdominal  veins  less  prominent. 

Fluctuation  remarkably  distinct. 

Uterus  lies  low  generally. 

Per  vaginam,  fluctuation  very  clear. 
Fluid  contains  no  albumen,  and  is  clear 

as   spring-water.     (Specific   gravity, 

3005.) 
Scarcely  ever  fills  after  tapping. 
Very  seldom  fatal. 


Broad  Ligament  and  Ovarian  Cyst. 

Ovarian  Cyst — Third  Stage. 
Common;    growth    more    rapid;    two 

forms  of  cystoma. 
Occurs  at  all  ages. 
Expression  changed ;  emaciation. 

Decidedly  impaired. 

Veins  more  developed. 

Less  distinct. 

Not  depressed,  but  behind  tumor  gen- 
erally. 

Less  clear. 

Contains  much  albumen,  and  is  not 
perfectly  transparent.  (Specific  grav- 
ity, 1015  or  more.) 

Fills  again  after  tapping. 

Almost  always  fatal  at  last. 


Differential  Diagnosis  of  Encysted  Dropsy  and  Ovarian  Cyst. 


Encysted  Dropsij. 

Is  extremely  rare.     Slow  increase. 

Preceded  by  attack  of  peritonitis. 

Features  natural.     Health  not  bad. 

No  dyspnoea  or  deranged  digestion. 

Abdomen  not  prominent,  at  points  even 
depressed. 

Veins  not  enlarged,  nor  lower  extremi- 
ties ojdematous. 

Fluctuation  not  strong;  limited  in  ex- 
tent, fluid  being  in  front  of  intes- 
tines. 

Per  vaginam,  no  tumor  felt,  and  gener- 
ally no  fluctuation. 


Ovarian  Cyst — Third  Stage. 
Common,  and  grows  rapidly. 
Preceded  by  good  health. 
Features  peculiar.     Health  impaired. 
Both  are  decided  symptoms. 
Everywhere  prominent. 

Veins  enlarged.     Extremities  not  very 

seldom  oedematous. 
Fluctuation    decided.       Intestines    on 

sides  of  cyst. 

Tumor  felt,  and  fluctuation. 


504 


DISEASES   OF  WOMEN. 


Uterus  in  place ;    sometimes  fixed   by    Behind  tumor  generally. 

adiiesions. 
But  little  liuid  obtained  by  tajjpinj,'.  Larger     quantity     obtained,     or    very 

large, 
J'luid  lias  characters  of  ascitic  fluid  and     Has  other  characters;  no  flakes  unless 
flakes  of  fibrin.  there  has  been  inflammation  of  the 

cyst-wall. 

Differential  Diagnosis  of  Ascites  and  Large  Ovarian  Cyst. 


Ascites. 
Previous  ill-health. 
Enlargement  comparatively  sudden. 
Face  full,  puffy,  leaden. 
Patient  on  back;  enlargement  is  sym- 
metrical, flat  in  front. 

Patient  on  the  side;  flatness  on  sides. 

Suddenly  rising  from  the  back;  fluid 
bulges  between  and  to  the  sides  of 
the  recti  muscles. 

Patient  sitting  up  ;  abdomen  bulges  be- 
low. 

Skin  of  abdomen  smooth,  tense,  shin- 
ing. 

On  superficial  view,  abdomen  very 
much  enlarged,  (Edema  of  extremi- 
ties in  all  cases,  and  at  last  of  abdo- 
men also. 

Floating  ribs  not  bulging. 

Navel  prominent  and  thinned. 

Fluctuation  very  decided  and  clear; 
diffused  through  abdomen,  but  avoids 
highest  parts  in  all  positions,  and  al- 
ways has  a  hydrostatic  level. 

More  distinct  in  erect  position. 

Percussion  gives  a  clear  tympanitic 
sound  at  highest  portions  of  abdomi- 
nal cavity  in  all  positions.  Is  dull 
elsewhere,  and  changes  with  the  po- 
sition. 

Aortic  pulsation  not  felt  through  ab- 
dominal walls. 

Vaginal  and  rectal  touch  detect  fluctua- 
tion at  once. 

Uterus  normal  in  size,   mobility,  and 

position ;  sometimes  prolapsed. 
Fluid,  a  light  straw-color;   coagulates 


Ovarian  Cyst. 

Good  health  previously. 

Enlargement  gradual. 

Face  emaciated ;  peculiar. 

Enlargement  is  not  usually  symmetri- 
cal ;  never  till  third  stage ;  prominent 
in  front. 

No  change  of  flatness. 

Sometimes  cyst  protrudes  thus  slightly, 
if  not  adherent. 

Little,  if  any,  change  of  abdomen. 

natural     or 


Abdominal     integuments 

merely  thinned. 
Superficial  view,  less  enlarged 

only  in  exceptional  cases. 


(Edema 


false 


Chest   conical    from   bulging   of 
ribs. 

Navel  not  thinned. 

Less  clear  and  decided ;  limited  by  the 
cyst.  May  remain  at  the  highest 
parts;  has  no  hydrostatic  level. 

More  distinct  in  recumbent  position. 

Clear  sound  only  at  part^  not  corre- 
sponding to  the  cyst,  and  in  both 
flanks;  dullness  over  it  in  all  posi- 
tions. 

Pulsations  are  transmitted  through  the 
cyst  to  the  abdominal  walls. 

Fluctuations  less  clear,  and  may  not  be 
reached  at  all,  or  not  exist  in  case  of 
polj'cyst. 

Uterus  displaced  behind  the  cyst  gener- 
ally. 

Fluid  a  darker  shade;  of  various  hues 


CYSTIO   TUMORS   OF   THE   OVARIES. 


505 


spontaneously  ;  contains  albumen  and 
aiiKJobold  corpuscles. 


Annaraia  supervenes  early. 

Uydragof^ues  and  diuretics  produce  tem- 
porary relief. 

Exceptions. — If  there  be  a  very  large 
accumulation,  may  be  dullness  at 
highest  point  of  abdominal  cavity, 
patient  being  on  the  back.  Or  the 
intestine  may  be  glued  down.  But 
deep  percussion  may  elicit  tympanitic 
sounds. 

And  one  or  both  flanks  may  be  clear 
from  gas  in  the  colon. 


in  polycysts;  abounds  in  albumen  or 
colloid  matter.  No  amosboid  corpus- 
cles. Never  coagulates  spontane- 
ously. 

Comes  on  late. 

These  remedies,  as  a  rule,  produce  no 
effect. 

Exceptions. — May  be  tympanitic  sound 
in  cyst  if  it  communicate  with  intes- 
tine. 


One  or  both  flanks  may  be  dull  from 
f?eces  in  the  colon. 


Differential  Diagnosis  of  the  Three  Varieties  of  Ovarian  Cysts.— Third 

Stage. 


Monocyst  and  Oligocyst. 

Slower  growth.  Not  un- 
common. 

Peculiar  expression  comes 
later. 

General  health  fails  much 
later. 

Abdomen  symmetrical ; 
if  monocyst  salient, 
pointed. 

Enlargement  from  thirty- 
five  to  forty -five  inches. 

Surface  smooth  if  mono- 
cyst. 

Tumor  disappears  after 
tapping. 

(Edema  of  lower  extremi- 
ties very  rare ;  abdomi- 
nal veins  less  enlarged 
and  later. 

Adhesions  less  common 
and  less  firm. 

Inflammation  of  cyst-wall 
not  common. 

Ulceration  of  cyst-wall  not 
common. 

Spontaneous  rupture  not 
common. 


Poly  cyst.  Dermoid  Cyst. 

Rapid     growth.        More  Congenital,     Very  slow. 

common.  Very  rare. 

Comes  much  earlier.  Latest  of  all. 

Fails   early  ;    by   end   of  Very  late. 

second  stage. 

Not    symmetrical  ;     not  Not  symmetrical, 

pointed. 

Sometimes  to    fifty  -  five  Smallest ;   generally  thir- 

or    even   seventy-eight  ty  to  forty  inches, 
inches. 

Lobulated ;  irregular.  A  monocyst,  as  a  rule. 

Does  not  disappear.  Does  not  completely  col- 
lapse. 

Very  common.   Veins  en-  Very  uncommon, 
larged  early. 


Adhesions  the  rule,  and    Adhesions  not  very  rare. 

vascular. 
Not  so  common.  Most    common,    propor- 

tionally. 
More  common.  Most  common  of  all. 


Far  more  common. 


Very  uncommoD. 


506 


DISEASES   OF  WOMEN. 


Comoa  iiiucli  earlier. 
Less  (listiDCt  aud  circuin 
scribed. 


Very  late. 

Fluctuation  more  obscure. 


Uterus  lower,  and  the 
liuctuation  also,  or  none 
at  all. 

Shorter,  as  a  rule. 

Not  clear,  brownish. dense, 
{gelatinous,  or  albumin- 
ous. 

Contains  also  blood-pig- 
ment and  blood-corpus- 
cles. 


Uterus  lower;  fluctuation 
dull. 

No  rule. 

Light  color,  curdy,  no  al- 
bumen, partly  soluble 
in  ether. 

Contains  epithelial  scales, 
sebaceous  matter,  crys- 
tals of  cholesterine, 
hairs,  etc. ;  a  single 
hair  is  pathogDomonic. 


Amenorrlicea  comes  later. 

Fluctuation  distinct  and 
throughout  if  a  mono- 
cyst,  and  from  any 
point  to  all  others. 

Per  vaginam,  uterus  is 
higher,  and  the  fluctua- 
tion also. 

Pedicle  longer,  as  a  rule. 

Fluid  limpid,  amber,  blu- 
ish, or  greenish,  viscid, 
with  much  al!>uraen. 

Contains  epithelial  scales, 
cholesterine,  and  fatty 
granules,  and  the  ovari- 
an glomeruli. 

Exception. — An  oligocyst 
of  but  two  or  three  con- 
stituent cysts  with  tliin 
partitions  may  give  all 
the  signs  of  a  monocyst. 

Prognosis. — The  progno.sis  in  ovarian  tumors  varies  greatly. 
Before  ovariotomy  was  practiced,  it  ran  almost  certainly  a  fatal 
course.  This  is  well  described  by  West,  and,  as  his  description 
gives  us  an  opportunity  to  show  how  much  modern  surgery  has  done 
to  lengthen  life  and  alleviate  suffering  in  these  cases,  I  will  quote 
it  in  full : 

"  We  have  symptoms  of  the  same  kind,  as  we  see  toward  the 
close  of  every  lingering  disease,  betokening  the  gradual  failure,  first 
of  one  power,  then  of  another ;  the  flickering  of  the  taper,  which, 
as  all  can  see,  must  soon  go  out.  The  appetite  becomes  more  and 
more  capricious,  and  at  last  no  ingenuity  of  culinary  skill  can  tempt 
it,  while  digestion  fails  even  more  rapidly,  and  the  wasting  body 
tells  but  too  plainly  how  the  little  food  nourishes  still  less  and  less. 
The  pulse  grows  feebler,  and  the  strength  diminishes  every  day,  and 
one  by  one  each  customary  exertion  is  abandoned.  At  first  the 
efforts  made  for  the  sake  of  the  change,  which  the  sick  so  crave, 
are  given  up ;  then  those  for  cleanliness ;  and,  lastly,  those  for  com- 
fort, till  at  length  one  position  is  maintained  all  day  long  in  spite 
of  the  cracking  of  the  tender  skin,  it  sufficing  for  the  patient  that 
respiration  can  go  on  quietly,  and  she  can  suffer  undisturbed. 

"Weariness  drives  away  sleep,  or  sleep  brings  no  refreshing. 
The  mind  alone,  amid  the  general  decay,  remains  undisturbed,  but 
it  is  not  cheered  by  those  illusory  hopes  which  gild,  though  with  a 


CYSTIC  TUMORS   OF  THE   OVARIES.  507 

false  briglituess,  the  decline  of  the  consumptive,  for  step  by  step 
Death  is  felt  to  be  advancing;  the  patient  watches  his  approach  as 
keenly  as  we,  often  with  acuter  perception  of  his  nearness.  We 
come  to  the  sick  chamber  day  by  day  to  be  idle  spectators  of  a  sad 
ceremony,  and  leave  it  humbled  by  the  consciousness  of  the  narrow 
limits  which  circumscribe  the  resources  of  our  art." 

If  there  is  malignant  disease,  or  if  there  are  so  many  adhesions 
as  to  make  the  removal  of  the  tumor  unwarranted,  the  prognosis  is, 
of  course,  most  unfavorable. 

If,  however,  the  case  is  one  in  which  ovariotomy  is  indicated,  the 
best  of  results  may  be  expected.  The  advances  made  in  sm-gery 
have  been  especially  noticeable  in  that  which  pertains  to  the  abdo- 
men, and,  as  a  result  of  this  great  advance,  the  mortality  in  cases 
which  are  treated  by  the  majority  of  ovariotomists  is  only  from  thir- 
teen to  fifteen  per  cent,  while,  under  the  skillful  manipulation  of 
Keith,  the  pioneer  of  ovariotomists,  the  mortality  has  been  reduced 
to  ten  per  cent.  This  magnificent  operator  has  had  seventy-six  con- 
secutive cases  without  a  single  death. 

The  removal  of  the  ovaries  that  are  not  (so  far  as  can  be  ascer- 
tained before  operating)  diseased  for  the  relief  of  certain  nervous 
symptoms,  and  also  for  the  relief  of  painful  and  otherwise  incurable 
diseases  of  the  uterus,  is  not  by  any  means  always  satisfactory.  The 
artificial  production  of  the  menopause  at  an  early  period  of  life  no 
doubt  may  produce  derangements  of  the  nervous  system  quite  as 
grave  as  the  condition  for  which  the  ovaries  are  removed. 

Causation. — Ovarian  cysts  may  occur  at  any  period  of  life,  and 
have  occurred  before  birth,  at  the  age  of  one  year,  three,  eight,  and 
twelve  years.  It  is  rare,  however,  that  this  form  of  ovarian  disease 
appears  before  puberty ;  from  this  period  to  the  menopause  it  occurs, 
as  a  rule,  and  is  especially  liable  to  arise  between  the  ages  of  thirty 
and  forty  years.  From  the  statistics  which  have  been  collected,  we 
must  infer  that  the  unmarried  are  more  disposed  to  develop  this 
affection  than  those  who  are  married.  Several  cases  have  been  re- 
ported in  w^hich  sisters  have  suffered  from  ovarian  cystoma ;  this  has 
led  some  authors  to  think  that  there  may  be  some  inherited  predis- 
position. I  am  inclined  to  think,  however,  that  these  may  be  coin- 
cidences, and  I  should  certainly  be  more  inclined  to  attribute  some 
such  influence  to  heredity  in  these  cases  had  the  patients  been  mother 
and  daughter,  rather  than  sisters.  There  is  no  reason  to  believe  that 
one  ovary  is  more  prone  to  cystic  degeneration  than  the  other,  al- 
though, as  a  rule,  but  one  ovary  is  affected  ;  this  occurrence  of  dis- 
ease in  both  ovaries  occurs  in  only  about  ten  per  cent  of  the  cases. 


508  DISEASES  OF   WOMEN. 

In  regard  to  the  causation  of  ovarian  tumors  of  all  kinds,  it  will 
be  seen  that  very  little  is  known.  The  subject  is  one  whicli  from 
its  very  nature  is  extremely  difficult  to  investigate,  and  it  will  proba- 
bly be  many  years  before  the  influences  whicli  are  active  in  produc- 
ing these  tumors  are  understood. 

When  the  cyst  is  developed  from  Graafian  follicles,  it  is  pre- 
sumed that  some  affection  of  these  follicles — intlammation,  perhaps 
— may  cause  the  dropsy  or  accumulation  of  fluid.  Dr.  Ncjeggerath 
believes  that  degeneration  of  the  blood-vessels  gives  rise  to  cystoma. 


CHAPTER   XXYIIL 

OVAKIOTOMY. 

The  operation  of  removing  ovarian  tumors  lias  been  generally 
known  as  ovariotomy.  Every  one  understands  the  meaning  of  the 
term,  established  by  usage,  as  indicating  the  removal  of  the  ovaries 
when  the  subjects  of  morbid  growths.  Since  Dr.  Battey  introduced 
the  procedure  of  removing  the  normal  ovaries  the  term  oophorectomy 
has  been  used  more  frequently,  and  there  appears  to  be  a  disposition 
among  some  to  use  the  term  ovariotomy  when  speaking  of  the  re- 
moval of  ovarian  tumors,  and  oophorectomy  when  referring  to  the 
removal  of  the  ovaries  when  not  enlarged.  This  use  of  two  terms 
which  mean  exactly  the  same  thing  is  confusing  in  any  case,  but 
much  more  so  when  an  attempt  is  made  to  make  the  terms  indicate 
different  operations.  I  shall  use  the  term  ovariotomy  in  all  cases 
when  treating  of  the  removal  of  the  ovaries,  no  matter  what  their 
condition  may  be. 

Ovariotomy  has  in  the  past  been  the  term  used  for  the  operation 
which  includes  the  removal  of  the  Fallopian  tubes  with  the  ovaries. 
In  nearly  all  the  ovarian  tumors  the  Fallopian  tube  is  so  united  to 
the  neoplasm  that  removal  of  the  one  necessitates  the  removal  of  the 
other. 

The  operation  first  practiced  by  Tait  and  Hegar  of  removing  the 
tubes  when  diseased  along  with  the  ovaries,  is  now  quite  generally 
spoken  of  as  removal  of  the  uterine  apj^endages.  This  is  a  very  un- 
satisfactory way  of  expressing  the  fact.  It  is  absurd  to  speak  of  the 
ovaries  and  tubes  as  aj)pendages  of  the  uterus.  One  might  as  well 
speak  of  hysterectomy  as  the  removal  of  the  ovarian  appendage. 
In  the  evolution  of  development  the  uterus  is  added  to  the  ovaries 
and  tubes  in  the  higher  animals,  and  ovaries,  tubes,  and  utenis  have 
independent  structures  and  functions ;  hence,  neither  one  is  an  ap- 
pendage to  the  other.  To  designate  the  operation  of  removing  the 
ovaries  and  Fallopian  tubes,  I  shall  use  the  term  tubo-ovariotomy. 


510  DISEASES  OF    WOMEN. 

GENERAL    CONSIDERATIONS    OF    OVARIOTOMY. 

Before  taking  up  the  details  of  the  operation,  I  sliall  call  atten- 
tion to  certain  general  facts  which  belong  to  all  Hurgical  procedures, 
and  have  a  special  bearing  on  ovariotomy.  While  most  that  will  be 
said  pertains  to  the  removal  of  ovarian  tumors,  it  will  be  equally 
applicable  to  the  removal  of  the  small-sized  di.^eased  ovaries  or  nor- 
mal ovaries  and  tubes,  the  more  modern  operation. 

I  have  long  entertained  the  opinion  that  ovariotomy  is  the  most 
difficult  operation  in  the  whole  field  of  surgery.  This  is,  however, 
a  matter  of  opinion,  and  may  be  an  error  on  my  part,  but  it  is  posi- 
tively certain  that  a  thorough  knowledge  of  surgery  and  all  attain- 
able dexterity  and  skill  in  operating  can  be  employed  M-ith  advan- 
tage in  removing  ovarian  tumors.  This  operation  differs  from  all 
othei's  that  I  know  of,  in  the  number  and  variety  of  complications 
which  it  affords.  It  is  seldom  that  two  cases  exactly  alike  occur  in 
the  practice  of  any  surgeon,  hence  it  is  not  until  a  very  large  num- 
ber of  cases  have  been  seen  that  the  operator  is  prepared  to  meet 
all  the  conditions  which  may  come  before  him.  To  the  operator  of 
limited  practice,  the  operation  in  this  respect  often  presents  the 
characteristics  of  a  new  investigation.  To  this  extent,  then,  the 
operation  is  unlike  anything  else  in  surgery.  Most  all  other 
operations  are,  to  a  great  extent,  definite ;  the  anatomy  being  the 
same  and  the  modus  operandi  fixed  according  to  well-defined  rules. 
The  surgeon  has  it  in  liis  power  to  learn  such  operations  by  practice 
upon  the  cadaver,  until  he  may  be  almost  master  of  his  work  (if  he 
has  in  him  the  surgical  diathesis)  before  touching  the  living  subject. 
iJ^o  such  opportunity  is  offered  to  acquire  the  art  of  doing  ovariot- 
omy. The  division  of  the  abdominal  walls,  the  first  and  simplest 
step  in  the  operation,  may  be  studied  and  practiced  upon  the  cada- 
ver, but  here  ends  the  value  of  dissection  as  a  special  aid  to  the  ova- 
riotomist. 

Books  and  lectures,  then,  are  the  most  available  sources  of  in- 
formation, but  this  reading  and  listening  to  others  talking,  although 
a  means  of  acquiring  a  knowledge  of  science,  is  a  poor  way  of  learn- 
ing how  to  perform  an  operation. 

It  is  true  that  one  may  familiarize  himself  Mnth  all  the  steps  of 
an  operation  and  the  complications  which  may  be  found  in  each  case, 
and  he  may  be  able  to  recall  them  at  will,  and  think  of  them  clearly 
before  and  after  an  operation,  but  to  recognize  the  indications  and 
promptly  meet  them  while  operating,  can  only  be  learned  by  prac- 
tical observation. 


OVARIOTOMY.  oil 

Tlie  first  essential,  tlien,  is  to  know  liow  to  operate — a  self-evident 
proposition  this,  which  need  not  he  made  here  were  it  not  for  the 
fact  that  many  try  to  perform  ovariotomy  who  are  not  (jiiaiificd  to 
do  so.  It  is  a  notorious  fact  that  this  most  important  of  operations 
has  been  performed  by  many  who  had  no  claim  to  being  called  sur- 
geons. Obstetricians  who,  having  turned  their  attention  to  some  of 
the  plastic  operations  of  gynecology  and  succeeded,  have  next  taken 
to  ovariotomy.  A  few,  bolder  still,  have  made  their  dehut  in  sur- 
gery as  ovariotomists,  without  any  previous  surgical  experience. 
Why  men  should  be  found  who  will  undertake  this  operation  while 
they  would  shrink  from  iridectomy  or  lithotomy,  is  a  difficult  ques- 
tion to  answer.  Perhaps  the  difficulties  in  the  way  of  learning  to 
do  this  operation  may  account  for  it. 

It  is  clearly  evident  that  one  should  be  well  grounded  in 
the  science  and  art  of  surgery  before  taking  up  ovariotomy.  The 
consummate  surgeon  can  readily  transfer  his  art  to  this  department 
of  abdominal  surgery  with  far  more  hope  of  success  than  one  who 
seeks  to  acquire  skill  by  practicing  ovariotomy  as  his  maiden  effort. 

The  best  and  surest  way  of  all  to  qualify  for  this  operation  is  to 
secure  facility  in  general  surgerj^,  and  then  to  take  lessons  of  some 
successful  operator  ;  to  witness,  and  if  possible  to  assist  in,  a  sufficient 
number  of  operations  so  as  to  see  the  different  kinds  of  cases  and  the 
various  complications.  By  such  means  the  surgeon  can  secure  one 
great  element  of  success,  a  knowledge  of  manipulations.  N^ext  to 
knowing  how  to  operate  is  how  to  obtain  competent  assistants.  An 
operator  of  large  experience  may  be  able  to  do  the  operation  with 
assistants  who  know  little,  if  anything,  of  the  operation,  his  famil- 
iarity with  the  work  being  such  that  he  can  give  much  of  his  atten- 
tion to  those  who  are  helping  him,  and  so  command  success.  It  is 
quite  different  with  one  of  more  limited  experience.  His  whole 
time  and  attention  are  taken  up  with  that  which  he  is  doing  himself, 
and  if  his  assistants  are  unacquainted  with  their  duties,  they  gener- 
ally hinder  rather  than  help.  It  is  a  sad  sight  to  see  a  beginner, 
with  untrained  assistants,  trying  to  do  ovariotomy.  The  ease  with 
which  such  assistants  make  simple  things  complicated  and  lose  time 
in  hurrying  is  quite  extraordinary.  I  know  this  from  having  played 
the  7'dle  of  operator  and  also  assistant  when  I  did  not  know  either 
of  the  parts. 

Skill  in  diagnosis  is  a  means  of  success  of  prime  importance, 
and  for  many  reasons  should  have  been  disposed  of  first ;  but  I  put 
the  operation  first  in  my  argument  simply  because  I  believe  that 
more  failures  come  from  poor  operating  than  from  errors  in  diagnosis. 


512  DISEASES  OF  WOMEN. 

The  text-books  give  all  the  rules  and  means  of  diagnosis  so  fully 
that  no  one  needs  more  theoretical  instruction — but  here  again  much 
practice  is  needed.  Diseases  of  the  ovaries  present  such  variety  of 
physical  signs  that  a  very  large  experience  is  required  to  see  all  the 
dLfferent  kinds  of  cases.  Ovarian  tumors  differ  so  in  their  form, 
composition,  and  complications  in  the  way  of  adhesions,  that  their 
real  nature  is  difficult  to  make  out.  Again,  there  are  many  abdom- 
inal tumors  and  products  of  disease  which  simulate  in  their  physical 
signs  ovarian  tumors  so  closely,  that  experts  of  long  practice  are  at 
times  unable  to  make  a  correct  diagnosis.  Still,  great  accuracy  can 
be  attained  in  diagnosis  by  long  and  careful  observation.  In  many 
affections  we  can  successfully  adapt  our  treatment  to  the  deranged 
conditions  manifested,  although  the  exact  nature  of  the  pathology 
may  be  unknown  ;  but  in  ovarian  tumors  we  must  have  rather  definite 
ideas  of  their  character  before  we  can  begin  their  surgical  treatment. 

Ovariotomy,  as  an  operation,  differs  so  much  with  the  different 
operators,  both  as  regards  the  methods  of  procedure  and  results  ob- 
tained, that  I  propose  to  notice  some  of  the  conditions  upon  which 
the  success  apparently  depends. 

Dexterity  on  the  part  of  the  operator  and  all  available  means 
which  save  time  and  secure  accuracy  are  obvious  necessities,  and 
need  not  be  urged  in  this  connection.  In  an  operation  of  such 
magnitude  the  question  of  anaesthetics  requires  a  passing  notice. 
Sulphuric  ether  has  still  the  best  reputation.  Its  administration 
should  be  prompt  and  carefully  kept  up.  The  less  ether  that  the 
patient  takes  the  less  the  danger  and  the  better  the  condition  of  the 
patient  afterward.  Fifteen  or  twenty  minutes  wasted  in  anaesthetiz- 
ing give  just  so  much  unnecessary  blood-poisoning,  and  this  to 
some  extent  retards  recovery.  Giving  nitrous-oxide  gas  first,  and 
follo^ving  it  up  with  ether,  is  the  most  rapid  way  of  anaesthetizing. 
I  have  seen  this  method  employed  by  others  with  great  satisfaction. 
I  use  ether  altogether,  and  administer  it  with  the  apparatus  already 
described,  and  am  perfectly  satisfied  with  the  method.  I  believe 
that  the  great  majority  of  ovariotomists  use  ether  as  an  anaesthetic, 
and  I  am  perfectly  satisfied  with  it  when  it  is  given  in  the  way  that 
I  have  mentioned. 

There  arc  a  number  of  points  of  importance  which  miglit  be  dis- 
cussed in  this  connection  in  regard  to  the  different  methods  of  sur- 
geons of  doing  certain  parts  of  the  operation.  When  describing  the 
operation  I  shall  give  the  methods  which  in  my  judgment  are  the 
best,  but  a  general  discussion  of  some  of  these  matters  appears  to  be 
necessary. 


OVARIOTOMY. 


513 


In  the  management  of  the  pedicle,  for  example,  we  find  that 
even  the  renowned  operators  do  not  all  agree.  Tiirough  the  influ- 
ence of  the  most  successful  of  all  operators,  I  am  firmly  convinced 
that  the  cautery  gives  the  best  results,  and  I  am  also  satisfied  that  it  is 
because  the  method  of  using  it  is  not  fully  understood  that  it  is  not 
more  generally  employed.  The  object  is  to  desiccate  at  least  half  an 
inch  of  the  end  of  the  stump  and  to  avoid  charring  it.  This  can 
only  be  accomplished  by  strongly  compressing  the  pedicle,  using  a 
heavy  clamp,  with  blades  half  an  inch  thick,  and  then  heating  it 


Fig.  198. — Cautery  clamp. 


with  a  very  heavy  cautery  until  the  portion  in  the  grasp  of  the  in- 
strument is  thoroughly  desiccated.  The  stump  thus  treated  looks 
like  a  piece  of  translucent  horn.  The  divided  ends  of  the  vessels 
are  completely  closed,  which  guards  against  haemorrhage.  I  pre- 
sume that  the  end  of  the  stump  does  not  slough,  but  becomes 
hydrated,  and  finally  organized. 

The  advantages  of  the  cautery  may  be  briefly  summarized  as 
follows  : 

It  is  a  reliable  way  of  controlling  haemorrhage ;  it  leaves  the  stump 
in  a  condition  requiring  the  least  reparatory  care ;  and,  finally,  it  avoids 
all  sources  of  irritation  such  as  that  to  which  the  ligature  gives  rise. 

I  have  recently  employed  a  cautery  clamp  which,  I  think,  has 
some  merits  worthy  of  notice.  It  compresses  the  pedicle  on  four 
sides.  The  long  blades  keep  the  tissues  from  spreading,  while  the 
short  sliding  blade  presses  the  tissues  against  the  other  cross-bar. 
The  advantage  of  this  is  that  the  pressure  upon  the  pedicle  is  equal 
nt  all  points,  and  it  thereby  gives  a  smaller  stump.  The  trouble 
with  the  old  straight  clamp  is,  that  it  spreads  out  the  pedicle  too 
much,  and  while  it  firmly  holds  the  central  or  thickest  part,  the 
outer  edges  are  liable  to  slip  out  of  its  grasp, 
34 


514  DISEASES   OF   WOMEN. 

The  next,  and  perhaps  the  most  iiuportaut,  essential  of  success  is 
cleanliness,  or,  to  put  it  tecLuicallj,  the  antiseptic  method  of  operat- 
ing. Surgeons  were  beginning  to  feel  a  certain  sense  of  security  in 
performing  ovariotomy  when  they  carried  out  all  the  details  of  the 
Listerian  method ;  but  more  recently  they  have  found  that  carbolic 
acid  in  place  of  saving  patients,  sometimes  sacritices  them.  When 
the  danger  of  carbolic-acid  spray  in  ovariotomy  was  first  announced 
many  surgeons  thought  that  Thomas  Keith  had  given  up  antiseptic 
surgery  ;  but  that  great  siu*geon  is  still  as  earnest  and  enthusiastic  in 
his  war  against  dirt  as  he  ever  was.  Although  he  has  given  up  the 
use  of  the  spray,  because  he  found  that  the  good  that  it  did  v.as 
counterbalanced  by  its  injurious  effects,  he  still  retains  all  the  other 
known  elements  of  antiseptic  surgery.  These  elements  I  under- 
stand to  be,  first,  to  keep  wounds  free  from  extrinsic  germs,  which 
are  in  themselves  injurious  to  living  tissues,  or  which  favor  morbid 
action  in  the  tissues  ;  and,  on  the  other  hand,  to  provide  for  the  es- 
cape of  morbid  material  which  may  be  developed  in  wounds.  To 
prevent  the  entrance  of  septic  germs  perfect  cleanliness  of  every- 
thing which  pertains  to  the  operation  is  necessary.  The  carbolic- 
acid  spray  can  at  most  only  disinfect  the  air  in  the  operating-room, . 
and  consequently  it  is  only  one  fraction  of  the  antiseptic  method  of 
operating.  Clean  operators  and  assistants,  clean  instruments,  sponges 
and  everything  which  may  directly  or  indirectly  come  in  contact 
with  the  patient  before,  during,  and  after  the  operation,  are  all  of  the 
highest  importance.  Still  more,  it  is  absolutely  necessary  to  keep 
all  things  clean  during  the  operation.  A  clean,  fair  start  may  be 
made  ;  but  during  the  operation  the  operator  s  hands  and  the  insti-u- 
meuts  may  become  contaminated  by  contact  with  the  contents  of 
the  cyst,  and  the  patient  be  exposed  to  septicaemia.  This  has  often 
occurred  when  the  spray  has  been  thoroughly  and  faithfully  used. 
Indeed,  if  too  much  dependence  is  placed  upon  the  spray,  there  is 
great  danger  of  contamination  from  want  of  care  in  other  respects. 
Some  of  the  fluid  contents  of  the  cyst  may  enter  the  abdominal  cav- 
ity, or  the  hands  of  the  operator  or  his  assistants  may  become  soiled 
from  the  same  source,  and  mischief  may  be  wrought  in  that  way. 
In  short,  it  is  exceedingly  difficult  to  guard  against  all  sources  of  un- 
cleanliness  in  this  complicated  operation.  I  think,  then,  that  if  all 
the  other  essential  elements  of  antiseptic  surgery  are  carefully  ob- 
served, the  spray  may  be  left  out  and  still  the  highest  success  can  be 
attained.  But  spray  or  no  spray,  too  much  can  not  be  said  in  favor 
of  antisepsis  in  relation  to  ovariotomy. 

There  is  still  another  fact  which  stands  out  prominently,  and 


OVARIOTOMY.  515 

upon  wliicii  success  depends,  and  that  is  the  management  of  the  dead 
material  which  may  be  unavoidably  left  in  the  abdominal  cavity,  or 
that  may  accumulate  there  after  the  operation.  Blood  or  bloody 
serum  or  the  contents  of  the  cyst  that  may  be  left  or  may  accumu- 
late in  the  peritoneal  cavity  is  dangerous,  and  should  be  removed  by 
drainage. 

It  is  true  that  within  the  last  year  or  two  there  has  been  some 
difference  of  opinion  regarding  the  value  of  drainage.  Some  of  tlie 
great  men  in  London  have  laid  it  aside  as  a  rule,  while  Keith  still 
employs  it  and  insists  that  he  saves  many  of  his  patients  by  it. 

I  believe  that  I  can  see  tliat  those  who  employ  drainage  have  the 
best  of  it.  I  incline  to  this  view  because  Keith,  who  practices  drain- 
age when  necessary,  has  had  the  highest  number  of  successes ;  and 
because  the  reasoning  against  drainage  by  those  who  have  given  it 
up  does  not  appear  to  fully  liarmonize  with  the  facts  in  the  case. 
It  is  claimed  that  if  ovariotomy  is  performed  with  all  the  attendant 
means  of  antiseptic  surgery,  including  the  spray,  any  fluid  which 
may  be  left  or  that  may  accumulate  in  the  peritoneal  cavity  is  harm- 
less. Spencer  Wells  states  that  fluids  do  not  accumulate  after  the 
use  of  antiseptics,  or  if  they  do  collect  they  do  not  putrefy,  but  are 
absorbed  without  injury. 

ISTow  it  is  difficult  to  understand  how  antiseptics  used  in  the 
operation  could  prevent  the  accumulation  of  serum  in  cases  where 
there  were  many  and  extensive  adhesions,  and,  on  the  other  hand,  it 
is  equally  incomprehensible  that  carbolic  acid  in  sufficient  quantity 
should  remain  in  the  abdominal  cavity  to  disinfect  the  fluids  which 
transude  from  broken  surfaces.  Without  daring  to  decide  the 
matter  or  to  express  any  positive  opinions,  I  may  state  that  the 
truth  appears  to  me  to  be  this :  Antiseptic  operating  will  lessen  the 
danger  to  a  very  great  degree,  but  there  will  always  be  cases  which 
call  for  drainage. 

The  value  of  drainage  depends  largely  upon  the  mode  of  using 
it.  The  metliod  which  I  have  usually  seen  practiced  in  this  country 
is  to  pass  a  tube  through  the  lower  angle  of  the  wound  down  into 
the  sac  of  Douglas,  and  then  to  close  its  outer  end  with  a  cork. 
This  cork  is  removed  several  times  a  day,  and  the  fluid  pumped  out. 
This  gives  a  kind  of  intermittent  drainage  wliicli  is  very  imperfect. 
The  method  which  I  obtained  from  Dr.  Keith  is  much  better.  In 
place  of  closing  the  end  of  the  tube  he  passes  it  through  the  center 
of  a  piece  of  rubber  cloth,  and  then  places  a  carboUzed  sponge  upon 
the  end  of  the  tube.  The  rubber  cloth  is  folded  over  the  sponge, 
and  tied  securely  with  a  string.     The  tube  and  the  sponge  are  thus 


516  DISEASES   OF   WOMEN. 

exeliuled  from  the  air,  and  aiiy  Huid  wbicli  accumulates  wells  up 
through  the  tube,  and  is  taken  up  by  the  sponge.  Tbe  8]>onge  is 
changed  several  times  a  day,  and  any  residual  tluid  which  may  re- 
main is  |)umped  out  at  each  dressing.  In  this  way  continuous  drain- 
age is  kept  up,  and  still  a  perfectly  antiseptic  dressing  is  maintained. 
This  may  aj)pear  to  be  a  simple  matter,  but  it  constitutes  the  differ- 
ence between  perfect  and  imperfect  drainage.  In  a  ca.se  o])erated 
upon  last  summer,  I  obtained  twelve  ounces  of  iluid  in  thirty-six 
hours  by  this  method  of  drainage,  and  the  temperature  of  the  pa- 
tient never  rose  above  normal,  excepting  one  day  when  it  reached 
one  hundred,  and  remained  there  for  a  few  hours.  This  case  alone 
would  be  sufficient  to  demonstrate  both  the  safety  and  value  of 
drainage. 

In  addition  to  the  requisite  skill  in  diagnosticating  ovarian  tu- 
mors, it  is  highly  essential  to  success  to  make  a  correct  estimate  of 
the  patient's  general  condition  before  operating. 

An  incipient  disease  of  some  of  the  organs  of  general  nutrition 
may  escape  the  notice  of  the  ovariotomist,  and  cause  a  fatal  issue,  no 
matter  how  skillfully  the  operation  may  be  performed.  Prominent 
in  this  regard  are  diseases  of  the  kidneys.  These  organs  should  be 
carefully  interrogated  in  all  cases  before  operating.  The  same  mle 
applies  to  all  the  important  organs  of  nutrition,  because  any  cardiac, 
hepatic,  pulmonary,  or  renal  lesions,  although  not  marked  or  threat- 
ening the  life  of  the  patient,  may  still  be  sufficient  to  turn  the  scale 
to  the  fatal  side  after  such  a  fonnidable  operation  as  ovariotomy. 

I  well  remember  one  case  which  illustrates  this  point.  The  pa- 
tient was  over  sixty  years  of  age,  and  appeared  fairly  well.  Her 
nutrition  was  poor,  it  is  true,  but  it  was  supposed  that  was  due  to  the 
size  of  the  tumor.  During  the  operation,  while  trying  to  control 
the  haemorrhage  from  adhesions  high  up  in  the  abdomen,  I  caught 
a  glance  of  the  liver,  which  was  far  advanced  in  fatty  degeneration. 
She  lived  a  week,  but  died,  as  I  think,  from  her  hepatic  disease 
rather  than  from  ovariotomy.  Had  a  more  complete  diagnosis  been 
possible  in  this  case,  I  would  have  had  one  less  on  the  unfavorable 
side  of  my  statistics. 

I  would  not  be  understood  as  saying  that  patients  should  not  be 
operated  upon  in  case  there  is  any  constitutional  affection  which 
might  complicate  the  case  and  lessen  the  chances  of  recovery,  but 
every  means  should  be  employed  to  get  the  patient's  health  in  as 
good  condition  as  possible  before  the  operation,  when  that  is  possi- 
ble. Sometimes  the  surgeon  is  not  called  until  the  patient  has  ad- 
vanced  so   far   that   no    time  is  given  for  preparatory   treatment. 


OVARIOTOMY.  517 

In  such  cases  patient  and  surgeon  must  take  the  risks.  In  regard 
to  preparatory  treatment  no  rules  need  be  laid  down  beyond  say- 
ing that  any  defect  in  health  or  strength,  or  functional  derange- 
ment of  any  kind  should  be  corrected.  Good  food,  sleep,  exercise, 
bathing,  and  pure  air,  with  such  medicines  as  may  be  needed  to  in- 
crease strength  or  meet  any  ordinary  requirements,  are  indicated. 
1  have  found  it  of  great  service  to  watch  my  patients  for  some  time 
before  operating  when  they  could  afford  the  time,  in  order  to  learn 
their  peculiarities,  mental  and  physical.  This  often  helps  the  sur- 
geon to  manage  them  better  after  the  operation.  In  brief,  then,  if 
the  patient  has  not  advanced  far  enough  to  demand  immediate  opera- 
tion, and  her  health  is  impaired,  an  effort  should  be  made  to  build 
up  her  strength  by  tonics  and  good  hygienic  conditions. 

The  time  most  favorable,  in  regard  to  the  season  of  the  year,  I 
think,  is,  in  this  country,  the  autumn  and  early  part  of  the  winter 
and  the  first  summer  months.  The  coldest  and  hottest  seasons 
should  be  avoided  if  convenient  to  do  so,  but  more  for  the  comfort  of 
the  patient  than  anytliing  particularly  unfavorable  to  success.  I 
have  Jiad  exceptionally  good  fortune  with  cases  that  I  have  been 
obliged  to  treat  in  June  and  July,  so  that  I  have  no  special  dread  of 
the  hot  weather,  if  everything  else  is  favorable.  The  spring  I  have 
found  the  most  objectionable  season.  The  confinement  in- doors  in 
winter  in  poorly  ventilated  houses  appears  to  impair  the  health  and 
strength  very  much.  This  holds  good,  to  some  extent,  in  both  city 
and  country.  In  regard  to  the  menstrual  period,  it  is  best  to  operate 
from  four  to  six  days  after  and  not  less  than  eight  or  ten  days  before. 
The  place  for  operating  should  be  an  institution  for  that  purpose. 
A  private  hospital  or  an  isolated  room  in  a  hospital,  free  from  con- 
tagious and  infectious  diseases,  should  be  preferred.  The  best,  of 
course,  is  an  isolated  building,  or  a  building  reserved  exclusively  for 
abdominal  surgery.  When  such  a  favorable  place  can  not  be  had  a 
private  house  is  next  to  be  preferred,  and  one  that  shall  be  in  the  best 
possible  sanitary  condition.  The  country  has  been  strongly  recom- 
mended as  the  best  place  to  operate.  I  am  quite  sure  that  there  is 
no  good  reason  for  this  preference.  If  all  the  comforts  and  sani- 
tary conditions  could  be  secured  in  a  country  house,  and  the  best 
attendance,  then  the  purer  air  of  the  country  would  be  more  desir- 
able than  the  city,  but  as  a  rule  the  wretched  sanitary  condition  of 
most  country  houses  gives  no  greater  advantages  over  city  houses 
for  abdominal  surgery. 

The  immediate  preparation  of  the  patient  for  the  operation  con- 
sists in  keeping  the  bowels  regular  by  some  mild  laxative  for  sev- 


518  diseasp:s  of  women. 

eral  day.s  before,  and  at  tlie  saiiie  time  giviiif;^  jtlain  food  whieli,  in 
tlie  experience  of  tlie  jxitient,  she  knows  agrees  with  her.  I  also 
give  five  grains  of  subnitrate  of  bismuth  and  the  same  quantity  of 
charcoal  twice  a  day  for  several  days,  to  dispose  of  intestinal  gases. 
This  is  important.  It  is  much  better  and  easier  to  operate  when 
the  bowels  are  empty,  especially  in  the  operation  of  removing  the 
ovaries  and  tubes. 

On  the  morning  of  the  day  before  the  operation  a  medium  dose 
of  castor-oil  should  be  given,  and  two  or  three  hours  before  the 
operation  I  give  one  grain  of  opium  and  three  grains  of  sulphate  of 
quinine. 

The  urine  should  be  examined  several  times  during  the  week  pre- 
ceding the  day  set  for  the  operation,  and  should  there  be  evidence 
of  any  well-marked  disease  of  the  kidneys,  the  operation  should  be 
abandoned.  If  there  is  no  renal  disease,  but  an  abnormally  high 
temperature,  the  operation  should  be  deferred  until  it  is  reduced, 
unless  the  high  temperature  is  due  to  suppuration  of  the  cyst. 

The  dress  of  the  patient  should  be  flannel  underclothing,  with 
woolen  stockings  and  a  flannel  dressing-gown,  which  opens  in  front, 
all  the  way  down.  Preferring  to  anaesthetize  the  patient  away  from 
the  operating-table,  I  have  this  done  in  an  adjoining  room.  Upon 
the  bed  or  sofa  on  which  the  patient  takes  the  ether  is  placed  the 
top  of  the  operating  table,  and  upon  that  she  lies. 

The  table-top  which  I  use  is  about  twenty  inches  wide  and  five 
feet  long,  upholstered  in  leather,  and  provided  with  straps,  by  which 
to  carry  it.  A  warm  blanket  is  wrapped  around  it,  and  it  is  placed 
on  the  side  of  the  bed,  and  the  patient  is  laid  upon  it  when  ether- 
ized, and  carried  to  the  operating-table.  When  the  operation  is  fin- 
ished, she  is  carried  back  upon  the  table-top  to  the  bed.  This  is  a 
most  convenient  way  of  moving  the  patient,  and  pays  well  for  the 
trouble  of  getting  an  operating-table  with  a  movable  top.  I 
have  a  frame  for  the  top  made  to  suit,  but,  when  operating  away 
from  my  private  hospital,  the  top  only  is  used,  and  is  placed  on  a 
small  table,  such  as  can  usually  be  found  in  every  house.  The  prep- 
aration of  the  room  in  which  the  operation  is  to  be  perfprmed  should 
be  made  as  follows :  If  it  is  a  room  built  on  purpose  for  abdominal 
surgery,  it  needs  no  further  treatment  than  a  thorough  disinfecting, 
and  then  airing.  The  windows  should  be  left  open  for  a  day,  and 
then  closed  and  the  room  filled  with  chlorine  gas,  and  kept  so  until 
near  the  time  for  oj)erating,  when  air  should  be  admitted,  to  make 
breathing  easy  and  comfortable.  The  air  admitted  should  be  from 
the  outside,  and  not  from  adjoining  rooms  or  halls.     If  the  opera- 


OVARIOTOMY. 


519 


tion  is  to  be  at  a  private  liouse,  the  carpet  and  all  drapery  should  be 
removed,  together  with  all  upholstered  furniture,  and  the  room  and 
all  necessary  furniture  should  be  disinfected  with  the  chlorine  gas. 
The  temperature  of  the  room  should  be  maintained  at  about  75°  F. 
The  necessary  instruments  and  appliances  difEer  to  some  extent  with 
each  operation.  I  shall  give  those  which  1  use  myself,  and  leave  the 
choice  of  special  instruments  which  may  be  deemed  necessary  to  in- 
dividual inclinations  or  judgment. 

List  of  Instruments  and  Apijliances  usually  required  iii  the 
Operation.— '^(fdk^Q\  with  fixed  handle;  dissecting-f orceps ;  artery- 


FiG.  199. — Keith's  short  compression-forceps. 


forceps;  six  Keith's  compression-forceps  (Figs.  199  and  200);  one 
vulcellum  forceps;  one  fenestrated  forceps;  small,  straight,  blunt- 
pointed  scissors ;  large,  straight  scissors ;  trocar  and  rubber  tube. 


Fig.  200. — Keith's  long  compression-forceps 


These  are  placed  together  in  an  enameled  pan  filled  half -full  with 
a  one-to-forty  carboKc-acid  solution. 

Twelve  to  twenty  sponges,  the  exact  numher  to  he  carefully  noted, 
prepared  and  placed  in  a  double  tin  pail  with  hot  water  in  the  outer 
compartment ;  six  towels  soaked  in  a  one  to-twenty  carbolic  solution, 
and  put  in  the  sponge  pail ;  No.  1,  3,  and  11  prepared  silk  for  liga- 
tures. 

These  should  be  cut  the  proper  length  for  ligating  thick  adhe- 
sions and  the  pedicle,  and  wrapped  in  gauze  and  put  into  the  car- 
bolic solution. 

No.  4  silk  for  the  abdominal  sutures  should  be  prepared  in  the 
same  way  ;  No.  2  catgut  ligatures ;  Keith's  needles,  two  for  each  ab- 


520 


DISEASES  OF   WOMEN. 


doiuiual  suture  (Fig.  201);  Peaslee's  needles;  Keith's  fine  forceps 
for  carrying  the  ligatures  ( Fig.  2(J2)  through  the  pedicle  ;  sutures  to 

^— -  -  -  -mi, 

b.T\tMKMHSi.Ca. 

Fio.  201. — Keith's  needle. 

be  used  with  Peaslee's  needle  if  required  ;  a  sheet  of  rubber  cloth, 
three  by  four  feet,  with  an  oval   hole  in  the  center,  the  border  of 


Fig.  202. — Keith's  hgature  forceps. 

which  is  coated  with  sticking-plaster  an  inch  wide  all  around  ;  long 
straps  of  saddle-girth  to  fasten  the  patient's  limbs  to  the  table ;  a  yard 
of  gauze  or  cheese-cloth  soaked  in  a  solution  of  one  part  of  carbolic 
acid  to  eight  of  glycerin  for  a  dressing ;  sheet  of  absorbent  cotton 
large  enough  to  cover  the  abdomen  ;  flannel  bandage  ;  safety-jiins. 

Instrum^nU   and   Appliances   that   may   he   needed. — Cautery 
clamps;   cautery  irons;   Baker-Brown's  clamp  (Fig.  203);  curved 


Fig.  203.— BakerBiown  Clamp. 


scissors :  concave  mirror ;  counter-pressure  instrument  for  tying  liga- 
tures in  abdominal  cavity  ;  several  drainage-tubes  of  different  sizes ; 
piece  of  sheet-rubber,  ten  by  ten  inches,  to  cover  the  end  of  the 
drainage  tubes ;  twelve  or  more  extra  sponges ;  twelve  to  twenty 
extra  compression-forceps  ;  aspirator ;  elastic  ligature. 

These  should  be  clean  and  placed  within  reach  of  the  operator, 
but  not  mixed  with  the  other  in.struments  named. 

The  instruments  to  be  used  should  be  placed  on  a  stand  beside 
tlie  operator,  and  also  a  basin  with  carbolic  solution,  or  such  disin 
fectant  as  the  surgeon  chooses  to  use  for  keeping  the  hands  clean. 


OVARIOTOMY. 


521 


The  sponges,  ligatures,  towels,  and  dressings  may  be  placed  beside 
the  first  assistant 

Assistants. — Three  assistants  are  certainly  needed,  and  one  more 
may  be  required.  One  gives  the  ether,  one  stands  on  the  left  side 
of  the  patient,  facing  the  operator,  the  third  on  the  left  of  the  op- 
erator, and  the  fourth  one  attends  to  the  washing  of  the  sponges. 

The  chief  assistant  on  the  opposite  side  of  the  table  sponges  the 
wound  during  the  incision  of  the  abdominal  walls,  holds  the  vessels 
or  adhesions  when  the  operator  is  ligating  them,  supports  the  cyst 
when  brought  out,  helps  to  apply  the  sutures  to  the  wound,  and  ful- 
fills all  orders  of  the  operator.  The  second  assistant  supports  the 
abdomen  and  cyst  or  tumor  while  the  abdominal  walls  are  being 
opened,  and,  when  the  cyst  is  being  removed,  he  helps  to  expel  it 
by  pressure,  and  at  the  same  time  prevents  the  escape  of  the  ab- 
dominal viscera. 

The  assistants  carry  the  patient  from  the  bed  to  the  table.  A 
blanket  is  wrapped  around  her  limbs,  and  a  rubber  bag  of  hot  water 


(^STAND.    WITH    INSTRUMENTS   AND    BASINS/|^ 


Fia.  204. — Position  of  operator,  assistants  and  accessories  in  the  operation.     Botli  arms 
sliould  lie  close  to  the  patient's  side. 

placed  at  her  feet.  The  strap  is  passed  over  the  thiglis  and  around 
the  table.  The  abdomen  is  made  bare  by  opening  the  dressing-gown 
and  raising  the  undergarment. 


The  rubber  cloth  is  spread  over  the 


522  DISEASES   OF   WOMEN. 

patient,  and  the  edges  of  the  opening  in  the  center  stuck  fast  to  the 
skin  around  the  lower  and  central  portions  of  the  abdomen.  One  of 
the  carbolized  towels  is  laid  over  the  thighs  of  the  patient,  upon 
which  are  placed  the  instruments  which  are  first  to  be  used.  This 
diagram  will  show  at  a  glance  the  position  of  all  concerned. 
The  several  steps  of  the  operation  are  as  follows : 

1.  Maldng  the  incision  in  the  abdominal  wall. 

2.  Exploring  for  adhesions. 

3.  Tapping  the  cyst  or  cysts. 

4.  Treating  adhesions  and  removing  tumor. 

5.  Treating  the  pedicle. 

6.  Examination  and  treatment  of  the  other  ovary. 

7.  Cleansing  the  abdominal  cavity. 

8.  Closing  the  incision. 

9.  Dressing  the  abdominal  wound  and  placing  the  patient  in  bed. 
The  details  of  the  several  steps  in  the  operation  in  uncomplicated 

cases  are  as  follows : 

The  incision  is  made  in  the  linea  alba — ^traces  of  which  can  usu- 
ally be  seen — down  to  the  muscular  layer.  The  length  of  the  incis- 
ion should  be  about  three  inches,  extending  from  one  inch  above 
the  pubes  upwards.  The  assistant  should  follow  the  knife  with  the 
sponge,  and  any  bleeding  vessels  should  be  caught  up  in  plain  for- 
ceps. The  tissues  at  the  bottom  of  the  wound  should  be  picked  up 
with  a  dissecting-forceps,  and  an  opening  made  in  the  median  line 
with  the  knife,  the  edge  of  which  should  be  directed  away  from  the 
tumor.  When  making  this  opening  care  should  be  taken  to  find 
the  median  line  between  the  muscles.  This  is  often  done  at  the  first 
trial,  but,  if  the  muscle  is  exposed,  its  sheath  should  be  followed  in 
either  direction  until  the  median  line  is  found,  and  then  another 
opening  made  there.  The  knife  is  then  put  aside,  and  one  blade  of 
the  blunt-pointed  scissors  is  introduced  into  the  opening,  and  the 
incision  completed  by  cutting  in  both  directions.  This  usually  ex- 
tends through  the  muscular  layer;  the  fascia  and  the  peritonaeum 
still  remain.     These  should  be  opened  in  the  same  manner. 

A  sound,  finger,  or  the  whole  hand  may  be  introduced  to  de- 
termine the  presence  and  character  of  adhesions,  if  such  exist.  The 
trocar  and  cannula  are  then  plunged  into  the  cyst  at  the  highest  end 
of  the  incision,  the  trocar  drawn  back  and  handed  to  the  assistant,  who 
takes  care  that  fluid  does  not  enter  the  abdominal  cavity.  The  cyst- 
wall  should  be  seized  with  a  lock-forceps  between  the  cannula  and 
left  side  of  the  incision.  This  is  also  handed  to  the  assistant,  who 
holds  it  and  the  trocar  in  his  left  hand,  and  makes  the  necessary 


OVARIOTOMY.  523 

traction  to  withdraw  the  cyst,  which  he  grasps  with  his  right  hand 
when  it  comes  out,  and  holda  it  without  making  traction  upon  the 
pedicle. 

The  operator  pushes  a  sponge  into  the  wound  behind  the  tumor. 
The  pedicle  is  then  examined  to  ascertain  its  size  and  character,  and 
whether  it  be  twisted.     The  cautery  clamp  (if  that  metliod  of  treat- 
ing the  pedicle  is  to  be  practiced)  is  then  applied,  and  the  pedicle  di- 
vided within  half  an  inch  of  the  clamp.     The  operator  then  sponges 
the  abdominal  cavity,  taking  special  care  not  to  leave  any  fluid  be- 
tween the  bladder  and  the  uterus.     The  assistant  meantime  takes 
care  of  the  clamp.     The  operator  examines  the  other  ovary,  and 
decides  whether  it  requires  to  be  also  removed  or  not.    One  or  more 
sponges  are  left  in  the  abdomen  while  the  pedicle  is  being  treated 
v\^ith  the  cautery.    Two  carbolized  towels  are  placed  under  the  clamp, 
and  the  remains  of  the  pedicle  are  removed  with  the  cautery.     The 
clamp  is  then  loosened  a  very  little  by  unscrewing,  and  the  cautery 
applied  until  the  clamp  is  heated  throughout  to  a  degree  that  will 
admit  of  the  flnger  being  flrmly  placed  upon  it.     Before  finishing 
the  cauterizing,  the  clamp  should  be  screwed  up  tight.     "While  the 
cauterizing  is  being  done,  the  assistant  should  remove  all  fluid  and 
debris  with  a  sponge  and  forceps,  and,  if  the  towels  beneath  the 
clamp  become  heated,  they  should  be  changed.     The  clamp  should 
be  cooled  with  a  moist  sponge  without  touching  the  cauterized  edge. 
The  pedicle  is  then  seized  with  two  forceps  below  the  clamp,  which 
is  gradually  and  with  great  care  loosened.     The  stump  of  the  pedi- 
cle should  be  watched  for  a  few  seconds  to  see  if  the  blood  inclines 
to  pass  up  any  of  the  vessels  in  the  part  that  has  been  cauterized. 
If  there  is  no  sign  of  such  taking  place,  then  the  stump  is  dropped 
back  and  covered  with  intestines,  and  the  omentum  over  all.    Should 
the  operator  decide  to  ligate  in  place  of  using  the  cautery,  the  pedi- 
cle is  secured  by  a  Baker-Brown  clamp  or  two  compression-forceps, 
and  a  double  ligature  is  passed  through  the  center  of  the  pedicle 
with  a  Keith's  ligature-forceps,  and  ligated  in  two  halves.     Care 
should  be  taken  to  cross  the  ligatures,  so  that  when  the  two  are  tied 
they  will  draw  the  tissues  together  in  one  mass.     When  the  pedicle 
is  small  and  long,  it  can  be  tied  before  cutting  away  the  cyst,  aiid 
without  using  a  clamp  at  all.     The  sponges  should  be  recounted  at 
this  stage  of  the  operation,  to  make  sure  that  none  is  left  in  the  ab- 
dominal cavity,  an  accident  which  has  occasionally  happened. 

A  flat  sponge  is  placed  over  the  omentum  and  beneath  the  edges 
of  the  wound,  and  left  there  while  the  sutures  are  being  introduced. 
All  bleeding  vessels  in  the  abdominal  wall  should  be  ligated.     Two 


524  DISEASES  OF  WOMEN. 

Keith's  needles  are  used  for  each  suture,  one  at  eacli  end.  The 
needles  are  introduced  from  the  inside  of  the  abdominal  wall,  and 
include  the  peritonaeum.  This  method  of  introducing  the  sutures 
is  the  quickest  and  the  best  when  the  incision  is  long  or  medium  in 
length,  but  when  the  incision  is  short  I  prefer  to  use  Peaslee's  needle 
of  smaller  size  than  that  which  is  usually  found  in  the  shops.  The 
needle  is  passed  from  without  inward,  and  the  suture  is  carried 
through  the  double  of  the  thread  in  the  needle,  and,  as  the  needle 
is  withdrawn,  the  suture- is  brought  into  place.  Having  introduced 
all  the  sutures,  the  ends  on  each  side  are  gathered  together  and  held 
while  the  flat  sponge  is  removed.  The  air  should  be  pressed  out  of 
the  abdominal  cavity,  and  the  sutures  tied.  Slip-knots  are  prefera- 
ble. The  sutures  should  be  close  together,  about  four  to  the  inch. 
Here  and  there  a  superficial  suture  may  be  needed  to  make  the  co- 
aptation as  complete  as  it  should  be.  The  dressing  of  gauze,  soaked 
in  the  one-to-eight  solution  of  glycerin  and  carbolic  acid,  is  applied, 
and  over  that  absorbent  cotton  and  a  flannel  bandage.  The  patient 
is  put  into  a  warm  bed,  and  hot  water-bags  or  bottles  put  around 
her,  and  one  sixth  or  one  quarter  of  a  grain  of  morphine  given  hypo- 
dermically. 

Complications. — The  several  steps  in  the  operation  are  liable  to 
be  complicated  by  a  variety  of  conditions.  The  chief  of  these  may 
be  mentioned  in  the  order  in  which  they  come. 

When  there  is  much  fat  beneath  the  skin  it  is  difficult  to  make 
a  straight  incision.  In  that  condition  the  wall  may  be  grasped  in 
the  left  hand,  raised  up  and  transfixed  with  the  bistoury  and  divided 
from  within  outward.  This  leads  down  at  once  to  the  muscular 
layer,  and  then  the  incision  is  finished  in  the  usual  way.  Great 
vascularity  of  the  abdominal  wall,  while  easily  managed,  takes  time. 
One  or  two  bleeding  vessels  may  be  caught  in  plain  forceps  and  con- 
trolled, but  when  there  are  many  it  is  better  to  tie  them  because  a 
number  of  compression-forceps  are  in  the  way  during  the  operation. 

Firm  adhesions  of  the  tumor  to  the  abdominal  wall  in  the  fine  of 
incision  are  often  a  troublesome  complication,  which  leads  the  opera- 
tor either  to  open  into  the  sac  before  knowing  it,  or  else  to  sepa- 
rate the  peritonaeum  from  the  abdominal  walls.  When  the  tumor 
can  once  be  reached  at  any  one  point,  it  is  very  easy  to  separate  the 
adhesions,  but  it  is  often  difficult  to  get  that  one  point.  Enlarging 
the  incision  is  a  help,  and  it  should  be  carried  in  the  direction  up  or 
down  according  to  the  possibility  of  reaching  a  point  where  the  cyst 
is  free.  Sometimes  the  exudation  which  forms  the  adhesion  can  be 
recognized  when  it  is  reached ;  it  is  then  easy  to  follow  it  up  until 


OVAKIOTOMY.  525 

the  detachment  is  complete.  When  the  cyst  is  exposed  all  the  par- 
ietal adhesions  should  be  loosened.  This  should  be  done  by  the 
hand.  When  the  tumor  has  been  of  slow  growth  and  is  tense  and 
the  walls  opparently  thick  and  strong,  a  very  great  amount  of  force 
can  be  used  in  separating  adhesions. 

If  the  tumor  is  flaccid  it  is  well  to  steady  it  with  a  pair  of  for- 
ceps while  separating  the  adhesions  and  before  introducing  the 
trocar. 

Parietal  adhesions  are  treated  before  tapping  the  cyst,  at  least  as 
far  as  they  can  be  easily  reached  by  the  hand. 


EMPTYING    THE    TUMOR    IN    COMPLICATED    CASES. 

In  multiple  cyst  and  multilocular  cases  in  which  the  contents 
of  the  sac  can  be  removed  by  tapping,  the  trocar  and  cannula  are 
thrust  into  the  nearest  cyst  and  it  is  emptied  in  the  usual  way ;  the 
trocar  is  then  pushed  into  another  sac,  which  in  turn  is  emptied, 
aud  so  on,  until  all  are  emptied.  To  do  this  safely  the  tumor  should 
be  steadied  with  the  left  hand,  while  the  trocar  is  used  with  the 
right,  and  this  helps  to  make  sure  that  the  trocar  goes  into  the  sac 
and  not  into  the  viscera  or  abdominal  walls. 

When  the  fluid  contents  of  the  tumor  are  semi-solid  and  will  not 
flow  through  the  cannula,  the  trocar  and  cannula  should  be  removed, 
and  the  opening  in  the  sac  enlarged  in  the  axis  of  the  body  ;  i.  e., 
the  opening  should  correspond  to  the  opening  in  the  abdominal 
wall.  A  pair  of  forceps  should  be  fastened  near  each  end  of  the 
opening  on  the  left  side,  and  perhaps  a  small  one  at  the  lower  end 
on  the  right  side.  These  forceps  are  held  by  the  assistant,  and  as 
the  tumor  becomes  smaller  he  draws  the  sac  out  and  down  until 
the  opening  in  the  sac  is  below  the  level  of  the  opening  in  the 
abdomen.  The  operator  introduces  his  hand  through  this  large 
opening  into  the  cyst  that  is  emptied,  and  breaks  down  the  other 
cyst-walls  and  sweeps  them  out ;  while  the  finger  of  the  right  hand 
is  boring  through  the  cyst- walls  tlie  tumor  is  steadied  with  the  left 
hand  on  the  abdominal  wall.  In  this  way  the  contetits  of  large  tu- 
mors may  be  br(jken  down  and  removed.  While  this  is  being  done 
the  edges  of  the  rubber  cloth  should  be  raised  so  as  to  direct  the 
fluid  into  the  tub  or  basin  at  the  side. 

When  the  tumor  is  very  vascular  and  great  bleeding  is  likely  to 
occur  in  emptying  the  contents,  the  pedicle  should  be  found  if  pos- 
sible and  compressed  with  catch-forceps. 

Adhesion  of  the  omentum  and  the  abdominal  and  pelvic  viscera 


526  DISEASES  OF   WOMEN. 

is  treated  after  the  tumor  is  emptied  of  its  liuid  contents.  The 
omental  adhesions  are  most  easily  tied  while  attachod  to  the  tumor, 
and  that  should  be  the  rule,  but  if  it  is  necessary  to  get  the  omen- 
tum out  of  the  way  before  the  operator  has  time  to  tie  it  i5roi)erly, 
compression-forceps  may  be  put  on,  and  the  whole  wrapped  up  in  a 
carbolized  towel,  and  left  on  the  abdomen  at  the  upper  angle  of  the 
wound  until  the  cyst  is  removed,  when  attention  can  be  given  it. 
It  should  then  be  tied  in  sections  of  about  the  width  of  two  hn- 
gers. 

Dr.  Keith  treats  adhesions  to  the  bowels  and  mesentery  by  mak- 
ing traction  upon  the  cyst  and  pressing  against  the  adhesions  with  a 
sponge.  In  this  way  the  adherent  tissues  can  be  pushed  apart  with 
less  injury  than  in  any  other  way.  Pulling  upon  adhesions  should 
always  be  avoided,  if  possible.  Sometimes  when  there  are  many  ad- 
hesions high  up  strong  traction  must  be  made,  there  being  no  other 
way  of  separating  the  timi  adhesions,  but  it  is  a  dangerous  practice 
and  only  to  be  resorted  to  when  it  can  not  be  avoided.  Long  bands 
of  adhesions  should  be  tied  before  being  detached,  and  the  following 
points  should  be  observed  ;  to  have  no  tension  upon  tliese  parts  ;  to 
ligate  as  far  from  the  free  end  as  possible,  and  make  sure  that  all 
bleeding  is  stopped  before  letting  go  the  parts.  The  bleeding  which 
comes  from  the  broad  adherent  surfaces  which  have  been  separated, 
should  be  controlled  by  placing  sponges  in  the  abdomen  and  making 
pressure,  and  as  soon  as  possible  bleeding  points  should  be  looked 
for  and  the  vessels  ligated.  When  the  sponges  are  removed  the 
position  of  the  bleeding  vessels  can  be  seen.  When  there  are  many 
adhesions  high  up  in  the  abdomen,  it  is  an  advantage  to  iind  the 
pedicle,  clamp  it  with  two  spring  catch-forceps,  and  divide  it,  and 
then  remove  the  tumor  from  the  pelvis  first.  When  the  adhesions 
are  all  treated  and  the  tumor  removed,  the  sponges  which  have  been 
introduced  should  be  removed,  and  the  bleeding  vessels  caught  up 
and  tied.  During  this  search  for  bleeding  vessels  in  the  pelvis  the 
assistant  holds  the  side  of  the  abdominal  wound  with  his  left  hand, 
and  with  a  concave  mirror  in  his  right  throws  light  into  the  pelvis. 
In  using  the  mirror  the  assistant  directs  it  so  that  he  himself  can  see, 
knowing  that  if  he  can  see  the  operator  will  see  also.  The  artilicial 
light  is  to  be  used  as  little  as  possible,  because  if  once  begun  it  is 
difficult  afterward  to  do  ^nthout  it. 

Drainage  should  be  employed  when  from  the  number  of  adhe- 
sions there  is  seen  to  be  a  free  transudation  of  serum  ;  when  all  the 
bleeding  has  not  been  or  can  not  be  stopped,  and  when  either  of  the 
above  conditions  ai-e  present  even  in  a  very  limited  degree  and  the 


OVARIOTOMY.  527 

patient  is  feeble.  In  cases  where  it  is  doubtful  wlietlier  drainage 
should  be  employed  or  not,  it  is  best  to  use  it. 

When  adhesions  to  the  intestines  or  pelvic  organs  are  so  firm 
and  extensive  that  they  can  not  be  separated  with  safety,  Dr.  T.  F. 
Miner,  of  Buffalo,  enucleates  the  tumor  or  cyst  from  its  peritoneal 
covering.  This  can  be  done  but  it  is  often  exceedingly  difficult  and 
there  is  left  a  large  surface  from  which  a  free  transudation  takes 
place,  and  requires  long-continued  drainage.  This  method  is  not 
practiced  much  now  ;  at  least,  I  hear  nothing  of  it. 

When  adhesions  are  very  extensive  and  firm  there  usually  has 
been  inflammation  of  the  cyst,  and  then  its  layers  can  not  be  sepa- 
rated ;  this  renders  enucleation  impossible. 

Treatment  by  Drainage  answers  in  such  cases  if  the  cyst  is  small 
or  of  medium  size.  If  the  cyst  is  adherent  to  the  abdominal  wall  it 
is  laid  open  without  being  separated  and  its  cavity  thoroughly 
cleaned  out,  and  a  drainage-tube  introduced,  and  kept  in  place.  The 
sac  is  washed  out  frequently,  and  when  it  has  contracted  down  it 
may  be  induced  to  close  by  the  use  of  tincture  of  iodine  and  car- 
bolic acid.  When  not  adherent  to  the  abdominal  wall,  but  so  gen- 
erally adherent  to  the  viscera  that  exploration  is  deemed  impossible, 
the  free  portion  of  the  sac  should  be  trimmed  off  and  its  edges  care- 
fully united  to  the  incision  in  the  abdominal  wall,  and  then  the 
di'ainage  practiced. 

I  am  aware  tliat  an  experienced  and  dexterous  operator  can  man- 
age verj'  bad  adhesions,  but  there  are  cases  where  it  is  safer  to  use 
drainage.  Five  cases  have  been  treated  in  this  way  in  my  own  prac- 
tice, and  four  of  them  recovered.  In  the  fifth,  a  bad  case  of  rupt- 
ured cyst  in  which  there  had  been  very  general  peritonitis,  the 
cyst  was  adherent  everywhere.  I  could  not  find  a  single  free  spot, 
and  the  patient  was  very  feeble.  The  sac  was  filled  with  inflamma- 
tory products,  which  were  carefully  cleared  out,  and  large  drainage- 
tubes  used.  She  improved  for  a  time  and  took  food  better  than  she 
had  done  before,  but  died  at  the  end  of  a  week,  apparently  from 
m'aemia ;  the  kidneys  were  found  to  be  diseased. 

In  case  of  very  intimate  adhesions  to  the  liver,  spleen,  uterns, 
bladder,  or  intestines.  Dr.  W.  L.  Atlee  did  not  detach  them  at  all, 
but  separated  the  peritoneal  from  the  middle  coat  of  the  cyst  at  the 
point  of  attachment,  and  left  it  there.  This  also  is  not  often  neces- 
sary, but  it  may  be  the  easiest  and  safest  thing  to  do,  and  if  drain- 
age is  employed  good  results  may  be  expected.  In  this  I  have  had 
no  experience. 

Arrest  of  Haemorrhage. — All  adhesions  in  the  form  of  bands  ex- 


528  DISEASES   OF   WOMEN. 

tending  from  the  cyst  to  other  parts  sliould  be  tied  before  dividing 
them.  This  applies  especially  to  adhesions  of  the  omentum. 
Large  bands  sliould  be  tied  with  prepared  silk  ligatures.  The  iiner 
bands  may  be  tied  with  catgut.  In  my  own  practice  I  use  silk  alto- 
gether. Intimate  adhesions  which  liave  to  be  separated  by  trac- 
tion leave  bleeding  surfaces,  and  if  any  large  vessels  are  found  they 
should  be  tied  if  possible.  General  oozing  can  usually  be  stopjied 
by  pressure  with  a  sponge.  Hivmorrhage  deep  down  in  the  i)elvis 
from  vessels  large  enough  to  be  ligated  can  be  reached  by  throwing 
in  the  light  from  the  mirror  and  using  a  long  artery-forceps.  The 
ligature  can  be  easily  tied  by  using  the  counter-pressure  instrument 
employed  in  tying  the  sutures  in  the  operation  for  restoration  of  the 
cervix  uteri. 

To  check  oozing  from  surfaces  like  the  uterus,  liver,  or  spleen, 
pressure  with  sponges  is  to  be  performed  as  stated  already.  An 
application  of  persulphate  of  iron  is  made  by  some  operators,  and 
the  thermo-cautery  has  also  been  commended.  Both  are  objection- 
able, and  should  be  avoided  if  possible. 

After-Treatment. — The  description  of  the  operation  ended  with 
the  giving  of  a  small  hypodermic  injection  of  morphia,  and  placing 
the  patient  in  a  warm  bed  in  a  room  at  a  temperatm'e  of  about  70° 
F.  She  should  be  kept  warm  so  as  to  induce  a  general  circula- 
tion, and  moisture  of  the  skin  from  gentle  perspiration.  Keith  in- 
sists upon  keeping  the  hands  covered  because  the  perspiration  will 
not  come  if  the  hands  are  exposed,  and  if  it  does  start  all  right,  put- 
ting the  hands  out  from  under  the  bedclothes  will  stop  it.  If  there 
is  nausea,  sips  of  hot  water  should  be  frequently  given.  When  all 
goes  well  there  is  very  little  after-treatment  needed  and  the  less  em- 
ployed the  better.  The  stomach  should  rest  until  the  patient  feels 
a  desire  for  food  or  drink,  and  no  food  should  be  given  by  the 
stomach  until  flatus  has  passed  from  the  bowels.  Solid  food  is  not 
given  until  asked  for  by  the  patient.  Pain,  if  severe,  should  be  re- 
lieved by  hypodermic  injections  of  morphia.  Excessive  vomiting 
may  be  controlled  in  the  same  way.  Flatulence  which  gives  dis- 
tress and  does  not  pass  off  is  most  effectually  managed  by  a  sohition 
of  quinine  administered  by  enema.  Dr.  Keith  told  me  about  the 
use  of  quinine  in  this  way,  and  I  have  used  it  very  often  and  with 
the  most  satisfactory  results.  Six  or  eight  grains  dissolved  in  aro- 
matic sulphuric  acid,  with  about  half  an  ounce  of  water  with  acacia 
enough  to  make  the  mixture  bland,  is  the  formula  used.  When 
about  to  use  it  warm  water  enough  is  added  to  raise  the  temperature 
of  the  mixture  to  that  of  the  rectum. 


OVARIOTOMY.  529 

This  I  have  found  will  relieve  flatulence  if  it  can  be  relieved  at 
ill,  and  is  at  the  same  time  a  good  way  of  supporting  the  patient, 
in  fact,  I  believe  tliat  its  action  in  relieving  flatulence  is  by  restor- 
ing the  tone  of  the  intestines. 

Should  the  stomach  remain  irritable  and  the  patient  be  weak, 
she  should  be  supported  by  soup  and  brandy  administered  per  rec- 
tum. The  bowels  should  usually  be  moved  by  enema  about  the 
tifth  or  sixth  day. 

The  patient  may  sit  up  about  the  fifteenth  day,  and  return  to  her 
usual  duties  in  about  four  weeks.  The  time  must  vary  in  each  case 
according  to  circumstances. 

The  management  of  the  various  complications  which  may  arise 
after  ovariotomy  will  be  discussed  with  the  histories  of  cases  which 
will  be  given  hereafter. 

Some  points  of  interest  regarding  diagnosis  and  treatment  will 
also  be  brought  out  in  the  clinical  records. 


35 


CHAPTEE  XXIX. 

ILLUSTEATIVE    CASES    OF   OVARIAN    NEOPLASMS. 

In  giving  the  liistories  of  ovarian  neoplasms  it  lias  been  deemed 
best  to  omit  simple  and  typical  cases,  because  they  would  add  noth- 
ing to  the  description  already  given.  The  following  complicated 
ones,  on  the  other  hand,  will  tend  to  convey  clearer  ideas  of  the 
pecuhar  cases  which  are  frequently  met  in  practice,  and  the  approved 
methods  of  management  adopted  at  the  present  time. 

Monocyst  of  the  Right  Ovary ;  Firm  Adhesions  to  the  Abdominal 
Wall ;  Necrosis  of  the  Posterior  Wall  of  the  Cyst ;  Ovariotomy ;  Re- 
covery.— The  patient  was  hf ty-four  years  old,  and  the  mother  of  four 
children.  After  the  birth  of  her  last  child,  the  attending  i:)hysician 
told  her  that  she  had  a  small  tumor  on  the  right  side  of  the  uterus. 
There  was  considerable  intermittent  pain  in  the  region  of  the  neo- 
plasm from  the  time  that  it  was  hist  discovered  up  to  the  time  that 
she  came  under  the  care  of  my  associate.  Dr.  Palmer,  four  years 
afterward.  The  growth  of  the  tumor  was  slow,  scarcely  noticeable 
for  the  first  three  years,  but  very  noticeable  during  the  last  year. 

When  she  first  came  under  the  care  of  Dr.  Palmer  the  tumor  ex- 
tended above  the  umbilicus,  and  fluctuation  was  well  marked. 
There  was  evidence  of  circumscribed  peritonitis,  and,  although  the 
tumor  was  movable,  adhesions  were  being  formed.  The  peritonitis 
was  quite  pronounced  at  this  time,  and  the  constitutional  symptoms 
were  well  defined.  She  was  treated  for  this,  and  in  about  two  weeks 
the  acute  symptoms  subsided,  but  she  still  remained  weak.  The 
doctor  sent  her  home  in  the  hope  that  she  would  gain  strength,  and 
the  tumor  being  still  small  there  was  no  urgent  necessity  for  its  re- 
moval. In  a  month  she  returned  to  the  hospital  not  improved. 
She  was  losing  flesh,  the  parts  were  still  tender,  the  appetite  poor, 
the  pulse  weak,  and  the  temperature  kept  above  100°  F. 

Another  effort  was  made  to  get  her  into  better  general  condition, 
but  without  success.     She  lost  strength  gradually,  and  it  was  de- 


ILLUSTRATIVE   OASES   OF   OVARIAN   NEOPLASMS.  531 

cided  that  the  only  chance  for  her  was  by  removing  the  tumor.  At 
this  time  the  adhesions  were  firm  and  involved  all  parts  of  the  ab- 
dominal wall  which  were  in  contact  with  the  tumor. 

Just  before  the  operation  the  pulse  was  120  and  the  temperature 
101°.  When  the  abdominal  incision  was  made,  the  adhesions  were 
very  firm  and  vascular,  except  in  a  small  space  just  above  the  sym- 
phisis pubis.  The  cyst  was  emptied  by  tapping,  and  the  lower  por- 
tion, which  was  not  adherent,  was  drawn  out,  and  the  pedicle  grasped 
with  strong  fixation  forceps,  and  divided.  The  adhesions  were  now 
easily  reached  and  separated.  The  pedicle  was  then  ligated,  and  the 
bleeding  stopped  by  pressure  with  sponges.  By  managing  the  pedi- 
cle in.  this  way,  the  tendency  to  bleeding  from  the  site  of  adhesions 
was  lessened  very  decidedly.  When  all  bleeding  had  stopped  the 
wound  was  closed  and  dressed  in  the  usual  way. 

An  examination  of  the  cyst  showed  a  portion  of  its  posterior 
wall  (about  the  size  of  one's  hand)  perfectly  bloodless,  of  a  dirty 
gray  color  and  friable,  indicating  that  it  was  necrosed.  No  doubt 
the  death  of  this  portion  of  the  sac  had  taken  place  many  days  be- 
fore the  operation,  and  I  presume  was  the  cause  of  the  constitutional 
disturbance. 

From  the  facts  in  this  case  and  from  those  observed  in  other  cases 
of  necrosis  of  the  cyst- wall,  I  believe  that  the  dead  tissue  causes  a 
form  of  septicaemia,  certainly  in  this  case  there  was  nothing  else 
found  to  cause  the  -high  temperature  and  pulse,  and  the  subsequent 
history  confirms  this  view. 

The  operation  was  performed  between  eleven  and  twelve  o'clock. 
She  soon  recovered  from  the  ether,  and  showed  no  depression.  At 
seven,  in  the  evening  her  condition  was  better  than  before  the  oper- 
ation. The  pulse  was  112,  temperature  99*5°  F.  and  respiration  20. 
During  the  night  she  had  slight  pain  in  the  abdomen  and  was  given 
a  hypodermic  injection  of  morphine.  She  slept  well,  and  had 
no  vomiting.  On  the  second  day  there  was  some  slight  distention 
of  the  abdomen  from  gas  ;  this  was  relieved  by  six  grains  of  sul- 
phate of  quinia  in  solution,  given  by  the  rectum. 

From  this  time  onward  her  progress  was  very  satisfactory.  The 
temperature  never  rose  above  99°  F.  Five  days  after  the  opera- 
tion the  bowels  were  moved  by  enema.  On  the  twelfth  day  she 
left  her  bed,  and  four  days  later  was  able  to  walk  about  the  ward. 
About  four  weeks  after  the  operation  the  left  leg  became  swollen, 
and  remained  so  for  about  a  week.  The  cause  of  this  was  not 
certain. 

She  was  discharged  from  the  hospital  at  the  end  of  the  fifth 


532  DISEASES   OF   WOMEN. 

week  feeling  perfectly  well  and  having  gained  flesh  and  strength 
surjirisiiiirly. 

Ovarian  Cyst  between  the  Broad  Ligaments,  Multiple  Cyst  of  the 
other  Ovary;  Ovariotomy  and  Hysterectomy ;  Eecovery. — This  i»atient 
was  under  the  care  of  my  friend,  Dr.  F.  II.  Stuait,  and  most  of  the 
facts  in  the  history  of  the  case — before  and  after  the  operation — are 
given  here  as  I  obtained  them  from  him. 

The  lady  was  iifty-six  years  of  age,  and  had  passed  the  meno- 
pause about  six  years.  At  the  age  of  thirty-nine  years  she  had 
a  pelvic  abscess  which  opened  into  the  bladder,  and  she  was 
then  sick  for  a  long  time.  About  three  years  before  the  time 
when  this  history  was  taken  she  noticed  a  tumor  in  the  right  iliac 
region. 

She  w^as  first  seen  by  Dr.  Stuart,  April  30,  1886.  lie  found 
the  uterus  high  up  behind  the  symphysis,  attached  to  an  elastic 
tumor,  which  was  immovable,  and  by  external  examination  appeared 
to  be  larger  than  a  fetal  head  and  extending  uji  into  the  right  iliac 
fossa.  There  were  two  other  tumors  of  smaller  size,  one  above 
and  one  to  the  left  of  the  larger  one.  These  appeared  to  be  adher- 
ent to  the  first  one,  and  were  also  rather  immovable.  1  saw  the 
patient  the  next  day  with  the  doctor,  and  confinned  the  diagnosis  of 
ovarian  cysts.  On  account  of  the  adhesions,  and  as  the  patient  was 
not  suffering  any  great  inconvenience,  we  thought  it  best  to  await 
further  developments. 

She  passed  a  very  comfortable  summer,  but  increased  steadily  in 
size,  with  a  corresponding  increasing  discomfort  in  locomotion. 
About  the  1st  of  December,  1886,  she  began  to  have  frequent  and 
painful  urination,  and  some  fever.  After  a  few  days  of  quiet  and 
some  quinine  (as  there  was  a  decided  intermittence  in  the  ii'ritabiUty 
of  the  bladder),  she  became  again  quite  comfortable. 

Immediately  before  the  operation  the  physical  signs  were  as  fol- 
lows :  The  general  outlines  of  the  enlarged  abdomen  were  irregular, 
three  cysts  could  be  majDped  out,  and  fluctuation  was  distinct  in 
each.  The  most  dependent  cyst  was  about  the  size  of  the  uterus  at 
the  seventh  month  of  utero-gestation.  and  occupied  the  center  and 
lower  region  of  the  abdomen.  It  was  not  movable  to  any  extent, 
and  appeared  to  be  separated  from  the  other  cysts  except  at  the  up- 
per and  right  side,  where  it  seemed  to  be  adherent  but  not  firmly 
so.  The  two  other  cysts  occupied  the  upper  and  left  lower  regions 
of  the  abdomen,  raising  the  diaphragm  and  causing  the  lower  ribs  to 
project  slightly.  These  two  cysts  could  be  moved  together  in  the 
abdomen,  but  were  closely  united  forming  one  tumor.     The  fluctua- 


ILLUSTRATIVE   CASES   OF   OVARIAN    NEOPLASMS.  533 

tion  was  very  clear  in  each  of  tliem,  but  was  not  distinctly  felt  through 
the  mass  formed  by  the  two. 

All  around  the  circumference  of  the  abdomen  there  was  dull- 
ness on  percussion,  and  distinct  Huctuation,  though  broken  at  points 
where  the  divisions  between  the  cysts  were.  These  signs  simply  in- 
dicated the  presence  of  a  multiple  cystic  tumor.  The  umbilicus 
was  high  up,  showing  that  the  lower  portion  of  the  abdominal  mus- 
cles was  distended  most,  and  in  a  space  about  five  inches  in  diame- 
ter in  the  umbilical  region  there  was  tympanitic  resonance  and 
gurgling  on  pressure,  showing  the  presence  of  intestines  at  that 
point.  Taken  altogether  the  abdomen  appeared  to  be  occupied  by 
a  large  cystic  tumor  with  a  mass  of  intestines  in  a  cup-shaped  space 
in  its  center. 

By  vaginal  touch  the  uterus  was  found  displaced  upward  and 
forward,  and  the  cervix  could  be  reached  without  difficulty,  owing 
to  its  being  crowded  toward  the  pubes.  Behind  the  uterus  and  ex- 
tending down  into  the  upper  and  posterior  portion  of  the  pelvis  a 
segment  of  cyst  was  found.  The  uterus  was  displaced  by  moving 
the  cyst  in  front,  and  pushed  forward  by  raising  the  cyst  behind  it. 
The  examination  indicated  very  certainly  that  there  was  a  cystic  ova- 
rian tumor  of  the  multiple  variety,  but  there  was  evidently  more 
than  that.  The  fact  that  the  uterus  was  involved  raised  the  ques- 
tion of  uterine  fibro-cyst,  as  well  as  ovarian  tumor,  but  there  was 
some  doubt  about  the  nature  of  the  whole  mass.  It  was  possible 
that  the  uterus  was  simply  adherent  to  the  cystic  tumor,  and  that 
the  adhesions  had  been  formed  while  the  tumor  was  still  in  the  pel- 
vis, and  the  uterus  had  been  carried  upward  as  the  tumor  grew.  It 
also  was  presumed  that  there  might  be  two  cystic  tumors,  and  that 
the  uterus  was  attached  to  one  of  these. 

While  the  exact  pathological  conditions  were  not  decided  upon, 
two  facts  were  quite  evident ;  tirst,  that  there  was  at  least  an  ovarian 
tumor,  and  that  the  patient  must  obtain  relief,  if  at  all,  by  ovariot- 
omy. 

Ojjeration. — After  making  the  abdominal  incision,  the  first  cyst 
was  exposed,  and  adhesions  of  the  omentum  were  found  on  the  right 
side.  The  omentum  w^as  vascular  and  its  adhesions  covered  the 
upper  part  of  the  tumor.  After  emptying  the  cyst  by  tapping,  the 
omental  adhesions  were  ligated  and  separated,  and  it  was  then  found 
that  this  cyst  had  no  connection  with  the  cysts  above,  but  was  situated 
between  the  folds  of  the  broad  ligaments,  and  extended  from  one 
side  of  the  pelvis  to  the  other,  between  the  uterus  and  the  bladder. 
The  uterus,  being  behind  the  cyst- wall  and  firmly  attached  to  it,  had 


534:  DISEASES   OF   WOMEN. 

been  stretclied  laterally  so  that  its  long  diameter  was  transverse. 
The  empty  cyst  was  held  outside  of  the  abdominal  wonnd  at  this 
stage  of  the  operation  by  forceps,  and  the  incision  extended  upward 
so  that  I  could  reach  the  other  tumor,  which  I  found  to  be  a  m.ulti- 
ple  cyst  of  the  left  ovary. 

The  four  largest  cysts  were  tapped  separately,  first  the  one  on 
the  right  side,  and  next  the  one  above  and  to  the  left,  then  the  one 
that  dipped  down  behind  the  cyst  of  the  broad  ligament  and  uterus, 
and  lastly  a  middle  one  between  the  upper  and  lower  cysts.  There 
was  a  deep  fissure  between  the  two  cysts  on  the  left  side  through 
which  the  intestines  found  their  way  up  to  the  abdominal  wall, 
which  accounted  for  the  tymj)anitic  resonance  obtained  during  the 
examination.  Tliis  tumor  had  an  ordinary  pedicle  starting  from  the 
left  posterior  surface  of  the  broad  ligament,  which  was  ligated  with 
silk,  and  the  tumor  removed. 

Having  disposed  of  this  tumor,  I  returned  to  the  cyst  of  the 
broad  ligaments,  and  upon  laying  it  open  and  inspecting  its  cavity,  I 
found  at  the  bottom  of  it  a  paj)illomatous  mass  which  had  the  ap- 
pearance of  an  epithelioma. 

I  then  undertook  to  enucleate  this  cyst,  the  lower  portion  of 
which  was  fixed  in  the  broad  ligaments,  between  the  bladder  and 
uterus,  as  already  stated,  but  the  adhesions  were  so  firm  and  the 
vascularity  so  great,  that  this  was  impossible.  I  then  tried  to  enu- 
cleate the  inner  wall  of  the  cyst,  but  this  was  also  impracticable. 
The  thought  occurred  to  me  that  I  miglit  stitch  the  cyst-walls  to  the 
sides  of  the  incision  in  the  abdominal  walls,  but  as  the  cyst  dipped 
down  into  the  broad  ligaments  on  both  sides,  two  pockets  would 
have  been  left,  which  would  have  been  difficult  to  drain.  The 
papillomatous  mass  in  the  central  part  of  the  sac  would  have  been 
left  also,  and  that,  I  presumed,  would  have  interfered  with  the  clos- 
ure of  the  sac.  and  the  final  recovery  of  the  patient. 

It  seemed  as  if  the  w^hole  thing  should  be  removed,  but  I  could 
not  take  in  all  the  tissue  involved  in  any  ordinary  clamp. 

I  then  tied  and  divided  the  broad  ligament  on  both  sides  from 
the  outside  toward  the  center,  so  as  to  f  onn  a  pedicle  which  could 
be  grasped  in  the  clamp.  The  bladder  was  dissected  from  the  cyst- 
wall  far  enough  to  let  the  clamp  get  down  below  the  uterus  and  the 
most  dependent  portion  of  the  sac.  Keith's  modification  of  Baker 
Brown's  clamp  was  then  applied,  and  the  cyst  and  uterus  removed. 

A  drainage-tube  was  introduced  above  the  clamp,  and  the  abdom- 
inal wound  closed  from  above  downward. 

The  operation  was  completed  at  noon,  and  five  minims  of  Ma- 


ILLUSTRATIVE   CASES    OF   OVARIAN   NEOPLASMS.  535 

gendie^s  solution  of  morplime  were  given  hypodermically  at  once. 
She  slept  quietly  for  about  two  hours  and  then  had  some  nausea,  and 
vomited  a  mouthful  of  mucus.  The  remainder  of  the  day  was  passed 
comfortably,  the  catheter  was  used,  and  sips  of  hot  water  were  given. 
At  midnight  the  temperature  was  99f  °  and  pulse  86.  The  second 
day  was  without  much  to  note  except  that  the  temperature  went  up 
to  101|-°  but,  toward  midnight,  it  came  down  to  100°  and  the  pulse 
was  86.  There  was  some  distention  of  the  bowels  which  was  relieved 
by  quinine,  given  by  the  rectum.  From  this  onward  the  patient 
did  very  well,  the  pulse  was  good  and  temperature  ranged  from  99° 
to  100°.  She  required  morphine  to  keep  her  comfortable,  but  noth- 
ing more. 

After  the  operation  the  kidneys  acted  very  well,  the  catheter  be- 
ing used  for  two  days,  and  after  that  the  patient  urinated  without 
trouble  and  passed  the  usual  quantity  of  water.  On  the  tenth  day, 
while  urinating,  the  dressing  of  the  wound  became  saturated  with 
urine,  showing  that  the  upper  part  of  the  bladder  had  opened ;  the 
dressings  were  removed,  but  the  opening  was  covered  by  the  clamp 
and  could  not  be  seen.  Several  times  afterward  when  she  urinated 
she  passed  a  very  small  quantity  of  water  by  the  urethra,  the  larger 
portion  passing  by  the  side  of  the  clamp.  Between  the  times  when 
she  urinated  there  was  no  leaking  from  the  opening  in  the  bladder. 
She  was  not  permitted  to  urinate  after  this ;  the  catheter  being  used 
at  regular  intervals. 

For  two  days  very  little  urine  escaped  from  the  opening,  and 
then  a  little  began  to  come,  which  made  the  wound  unclean. 

It  being  quite  evident  that  the  stump,  below  the  clamp,  had  un- 
dergone necrosis  to  a  considerable  extent,  an  elastic  ligature  was 
passed  around  the  stump,  below  the  clamp,  in  the  hope  that  it  would 
cut  its  way  through  the  softened  and  dead  tissues,  and  set  the 
clamp  at  liberty  ;  it  did  so  to  a  limited  extent  only,  and,  as  it  was 
very  difficult  to  keep  the  wound  clean,  the  clamp,  on  the  fifteenth  day 
after  the  operation,  was  carefully  liberated  by  dividing  the  dead  tissues 
of  the  stump  with  the  knife  and  scissors.    No  haBmorrhage  was  caused. 

When  the  clamp  was  removed,  it  was  found  that  the  necrosis  of 
the  tissue  extended  farthest  on  the  right  side,  and  it  was  at  this  point 
where  the  bladder  was  open.  At  first  it  was  thought  that  the  blad- 
der had  been  included  in  the  clamp ;  but  that  did  not  seem  possible, 
because  of  the  extreme  care  taken  to  avoid  it  when  applying  the 
clamp,  and  also  from  the  entire  absence  of  all  functional  disturb- 
ance of  the  bladder  during  the  ten  days  immediately  succeeding  the 
operation. 


536  DISEASES   OF   WOMEN. 

After  removing  the  clamp,  and  seeing  how  far  the  death  of  the 
tissues  of  the  stump  liad  extended  on  the  right  side,  it  appeared  that 
the  opening  of  the  bladder  was  due  to  this  destruction  of  the  tissues. 
The  opening  occurred  on  the  right  (as  has  been  already  stated),  at 
the  site  of  the  old  cellulitis,  which  she  had  years  ago,  and  where  the 
abscess  discharged  into  the  bladder,  in  all  probability,  and  this  may 
account  for  the  death  of  the  tissue  below  the  clamp. 

During  the  operation  it  was  noticed  that  the  right  broad  liga- 
ment was  thickened  greatly,  and  changed  in  appearance,  owing  no 
doubt  to  the  products  of  the  old  inflammation,  and  the  damaged  state 
of  the  tissue  probably  favored  the  necrosis ;  this  may  have  been 
also  favored  by  the  pressure  of  the  abdominal  wall.  The  pedicle 
was  broad,  so  that  it  stretched  the  wound,  and  the  pressure  of  the 
strongly  retracted  edges  of  the  wound  may  have  helped  to  strangu- 
late the  right  side  of  the  stump,  the  vitality  of  which  was  of  a  low 
order. 

The  dressing  of  the  stump  and  abdominal  wound  now  became  a 
rather  difficult  task,  owing  to  the  escape  of  urine.  Iodoform  and 
absorbent  cotton  did  best  of  all.  Although  the  catheter  was  used, 
there  still  was  some  leaking  above.  The  urethra  became  tender  to 
the  passing  of  the  catheter,  and  then  the  doctor  tried  keeping  it  in 
the  bladder  continuously.  This  did  well  for  a  time,  but  had  to  be 
given  up  because  of  the  pain  caused.  By  the  free  use  of  cocaine 
the  catheter  could  be  used,  so  that  the  leaking  in  the  wound  was  not 
great.  During  all  this  time  her  general  condition  was  fairly  good, 
but  the  wound  healed  slowly,  and  she  needed  morphine  to  keep 
her  comfortable. 

About  this  time  several  of  the  ligatures  used  in  tying  the  broad 
ligament  on  the  right  side  came  away  through  the  wound.  About 
five  weeks  after  the  operation,  and  while  she  was  apparently  well, 
except  that  the  fistulous  opening  of  the  bladder  remained  and  her 
strength  had  not  returned  fully,  she  was  taken  quite  ill ;  the  tem- 
perature ran  up  to  103°,  and  the  bowels  became  constipated ;  the 
appetite  was  entirely  lost,  and  she  looked  badly  in  the  face,  and  lost 
flesh  rapidly. 

There  was  a  hard,  irregular  mass  felt  in  the  right  side  of  the 
abdomen  at  this  time,  which  was  presumed  to  be  a  local  inflamma- 
tion due  to  the  ligatures  used  in  ligating  the  omentum.  The  doctor 
and  I  were  not  without  some  fears  that  it  might  be  the  beginning 
of  some  malignant  disease,  but  it  proved  not  to  be  so.  Quinine 
given  by  inunction  and  the  rectum  controlled  the  fever  after  a  time, 
and  then  the  stomach  and  bowels  began  to  act  again. 


ILLUSTRATIVE   OASES   OF   OVARIAN   NEOPLASMS.  537 

From  this  time  her  progress  was  favorable,  and  she  is  now  (one 
year  after  the  operation)  perfectly  well, 

A  Papillomatous  Monocyst  of  the  Ovary.  Ovariotomy.  Fatal 
Termination  from  Haemorrhage. — The  patient  was  thirty-five  years 
old.  She  had  had  two  children.  For  about  one  year  before  the 
ovarian  tumor  was  detected  she  suffered  from  menorrhagia.  When 
I  first  saw  her  she  was  quite  anaemic  from  long-continued  and  pro- 
fuse menstruation,  caused  by  polypoid  fungosities  of  the  uterine 
mucosa.  She  was  promptly  relieved  by  curetting.  At  that  time 
the  ovarian  cyst  was  about  the  size  of  a  pregnant  uterus  at  four  and 
a  half  months.  The  cyst  increased  in  size  rather  slowly.  She  had 
two  attacks  of  circumscribed  peritonitis,  one  at  the  upper  part  of 
the  cyst,  which  gave  rise  to  adhesions  to  the  abdominal  wall  above 
and  to  the  left  of  the  umbilicus.  About  eight  months  from  the 
time  that  I  first  saw  her,  and  after  the  slight  attacks  of  peritonitis, 
she  was  attacked  with  severe  pain  in  the  region  of  the  cyst,  but  there 
was  no  evidence  of  inflammation. 

At  this  time  the  cyst  became  very  tense,  and  there  was  general 
tenderness  and  heavy  pressure.  These  symptoms  subsided  for  a 
time,  but  there  were  several  attacks  of  this  kind,  each  one  being 
marked  by  a  sudden  increase  in  the  tension  of  the  cyst.  The  patient 
continued  to  be  rather  anaemic,  there  were  wandering,  ill-defined 
pains  in  the  abdomen,  and  the  general  condition  showed  that  she  suf- 
fered more  than  is  usual  in  cases  of  uncomplicated  ovarian  cystoma. 

This  led  to  the  determination  to  operate,  though  the  size  of  the 
cyst  did  not  demand  immediate  interference. 

When  the  wall  of  the  abdomen  was  opened,  and  the  cyst  exposed, 
it  was  darker  in  color  than  it  should  be ;  adhesions  were  found  at 
the  upper  and  left  side,  and  also  low  down  and  near  the  median  line. 
Tapping  was  tried,  but  the  contents  of  the  cyst  would  not  flow.  The 
sac  was  then  opened,  and  its  contents  were  found  to  be  blood  and 
old  blood-clots  with  very  little  ordinary  ovarian  fluid.  It  was  neces- 
sary to  pass  the  hand  into  the  cyst  to  evacuate  its  contents ;  this 
caused  fresh  and  profuse  bleeding.  The  patient  showed  the  loss  of 
blood  very  rapidly;  great  haste  was  made  to  separate  the  adhesions, 
which  were  very  vascular  and  required  ligating. 

The  depression  became  more  and  more  marked,  and  it  looked  as 
if  the  patient  would  die  on  the  table.  The  cyst  was  hurriedly  re- 
moved, and  the  abdominal  wall  was  closed.  There  was  some  oozing 
from  the  adhesions,  and,  as  there  was  little  time  for  sponging  the 
peritoneal  cavity  and  stopping  the  bleeding,  which  was  only  a  very 
little  oozing,  a  drainage-tube  was  used.     The  patient  rallied  a  little, 


538  DISEASES  OF    WOMEN. 

and  tliere  were  ])opes  that  she  might  be  saved.  There  was  consid- 
erable discharge  of  bloody  serum  from  the  tube,  which,  in  place  of 
becoming  less,  as  I  expected  it  would,  increased.  Whenever  the 
pulse  improved,  and  the  patient  gained  a  little  strength,  the  bleed- 
ing increased.  It  was  never  free  enough  to  warrant  my  opening 
the  abdomen  to  stop  it,  but  kept  on  just  enough  to  keep  the  patient 
down.  At  the  end  of  the  third  day  there  was  very  little  bleeding, 
and  there  was  a  promise  of  success,  but  then  she  began  to  show  signs 
of  heart-clot,  and  she  died  on  the  fourth  day. 

The  inside  of  the  cyst  was  Uned  with  a  layer  of  papillomatous 
material,  which  presented  a  cauliflower  appearance  not  unlike  that 
of  epithelioma  of  the  cervix  uteri. 

The  points  of  greatest  interest  in  the  history  of  this  case  are  the 
frequent  hfemorrliages  which  took  place  in  the  cyst  during  its  growth 
and  the  unsatisfactory  character  of  the  operation  which  permitted 
the  loss  of  so  much  blood.  There  is  no  doubt  in  my  mind  but  that 
the  attacks  of  distress  and  extreme  and  sudden  distention  of  the  sac 
were  due  to  the  haemorrhages  in  the  cyst.  This  view  of  the  matter 
was  confirmed  by  the  large  number  of  blood-clots  which  were  found 
during  the  operation.  The  evidence  of  these  extra  cystic  haemor- 
rhages was  so  marked  and  pecuhar  that  I  am  sure  a  diagnosis  could 
be  made  with  certainty  in  similar  cases.  This  would  be  a  great  gain, 
because  it  would  enable  one  to  operate  before  the  frequent  losses  of 
blood  had  weakened  the  patient,  and  while  the  cyst  was  small,  and 
could  be  more  easily  removed — two  advantages  which  would  tend  to 
the  safety  of  the  patient. 

There  were  several  unfortunate  incidents  in  the  operation  which 
could  have  been  in  part  prevented  had  I  had  more  experience  in 
such  cases.  In  the  first  place,  when  the  patient  was  anaesthetized, 
the  cyst  was  handled  with  considerable  force  for  the  purpose  of  de- 
termining the  presence  and  extent  of  the  adhesions.  This,  I  am 
sure,  started  the  bleeding,  which  might  have  been  avoided.  When 
the  cyst  was  opened,  and  the  active  ha?moiThage  detected,  I  should 
have  found  the  pedicle,  and  temporarily  controlled  it  with  com- 
pression-forceps. This  ^vould  have  saved  much  of  the  haemorrhage, 
and  then  I  could  have  taken  time  to  treat  the  adhesions  properly. 

These  facts,  I  beheve,  explain  fully  the  failure  in  the  case,  and 
they  throw  much  valuable  light  on  the  diagnosis  and  treatment  of 
this  peculiar  variety  of  ovarian  neoplasm. 

Ovarian  Cyst  between  the  Folds  of  the  Broad  Ligament.  Incom- 
plete Removal  of  the  Cyst ;  the  Remaining  Portion  treated  with  Drain- 
age; Recovery.--This  lady  was  thirty-five  years  old,  and  had  been 


ILLUSTRATIVE   OASES   OF  OVARIAN  NEOPLASMS.         539 

married  nineteen  years.  Her  general  health  had  been  fairly  good, 
but  slie  did  not  menstruate  until  she  was  nineteen  years  of  age. 
The  menstrual  flow  had  always  been  scanty  and  of  short  duration, 
and  she  never  had  been  pregnant. 

These  facts  indicated  that  probably  the  sexual  organs  were  im- 
perfectly developed.  About  one  year  before  she  came  under  my 
care  she  noticed  a  small  tumor  in  the  right  side  of  the  abdomen,  low 
down.  It  steadily  increased  in  size,  and  then  she  lost  flesh  and 
strength,  and  sirflicred  from  pain  in  the  abdomen  and  back,  and  her 
appetite  failed.  When  flrst  seen  by  me  she  had  a  bronzed  appear- 
ance, was  feverish,  and  the  pulse  was  fast  and  rather  weak.  She 
had  the  general  appearance  of  one  in  the  last  stage  of  ovarian  dropsy, 
and  also  cachectic.  The  tumor  was  about  the  size  of  the  uterus  at 
the  seventh  month  of  pregnancy.  It  was  very  hard,  and  fluctuation 
was  very  indistinct.  Though  not  apparently  adherent  to  the  abdomi- 
nal wall  the  tumor  was  not  at  all  movable.  It  was  firmly  fixed  in 
the  pelvis,  and  there  was  mucli  tenderness. 

By  the  vaginal  touch  the  hard  tumor  was  found  deep  down  in 
the  pelvis,  firmly  fixed,  and  not  the  slightest  fluctuation  oi-  elasticity 
could  be  detected.  The  uterus  was  pushed  to  the  left  and  upward, 
so  that  it  partly  occupied  the  left  iliac  fossa.  The  irregularity  of 
the  surface  of  the  tumor,  as  felt  through  the  vagina,  indicated  that 
it  was  surrounded  by  the  products  of  inflammation. 

The  physical  signs,  as  observed  by  the  vaginal  touch,  were  such 
as  would  indicate  a  uterine  fibroid  developed  in  the  right  broad  liga- 
ment, but  the  character  of  the  tumor,  as  felt  in  the  abdomen, 
showed  that  it  was  a  cyst.  The  question  of  fibro-cyst  was  then 
raised,  but  the  history  of  the  case  was  not  in  favor  of  this.  While 
there  was  little  doubt  regarding  the  true  nature  of  the  tumor  I  fav- 
ored the  diagnosis  of  ovarian  cyst  complicated  by  inflammation  of 
the  cyst-w^alls. 

The  patient  was  placed  under  treatment  in  the  hope  of  improving 
her  digestion  and  general  health,  but  beyond  relieving  her  consti- 
pation and  flatulence  there  was  no  real  gain.  Her  pulse  remained 
about  98,  and  her  temperature  fluctuated  between  99°  and  101°. 
During  thp  few  days  that  she  was  under  observation  the  cyst  became 
a  little  less  tense  so  that  fluctuation  could  be  more  surely  made  out. 

The  chief  points  of  interest  in  the  operation  were  as  follows.  The 
tumor,  easily  and  fully  exposed  by  an  incision  three  inches  long 
through  the  abdominal  walls,  was  adherent  to  the  omentum  over  its 
entire  anterior  surface.  The  cyst  was  emptied  by  aspiration  of  its  con- 
tents which  contained  pus  and  lymph.     The  omentum  was  ligated 


540  DISEASES  OF   WOMEN. 

in  sections  with  silk,  and  detacbed  from  tlie  cyst-wall.  It  was  then 
found  that  tlie  folds  of  the  broad  ligament  covered  the  cyst  com- 
pletely, and  were  so  intimately  blended  with  the  walls  of  the  cyst 
that  they  could  not  be  separated  to  any  extent.  Careful  and  ])ersist- 
ent  efforts  were  made  to  enucleate  the  cyst,  but  in  vain.  The  open- 
ing in  the  cyst  was  temporarily  closed  with  forceps,  and  the  left 
ovary  looked  for.  It  was  found  far  over  on  the  left  side  and  con- 
tained several  small  cysts.  It  was  removed  in  the  usual  way.  The 
major  portion  of  the  cyst-walLs  and  broad  ligament  was  then  re- 
moved, and  the  larger  vessels  ligated  to  control  hemorrhage.  An- 
other effort  was  made  to  enucleate  the  remainder  of  the  cyst-walls, 
but  they  extended  so  deep  down  into  the  pelvis  and  the  tissues  were 
so  exceedingly  vascular  and  matted  together  by  inflammatory  prod- 
ucts that  it  could  not  be  done.  The  remains  of  the  ligament  and 
cyst-w^alls  were  carefully  stitched  to  the  abdominal  wound,  the  sac 
carefully  sponged  clean,  and  a  large  drainage  tube  introduced. 

The  after-treatment  and  progress  of  the  case  were  as  follows : 
She  had  for  the  first  two  days  considerable  nausea  and  pain.  For 
this  she  was  given  hypodermic  injections  of  morphine.  The  sac 
was  washed  out  thoroughly  every  four  or  eight  hours  according  to 
her  temperature.  There  was  not  much  nourishment  taken  during 
the  first  six  days.  The  pulse  and  temperature  varied  greatly.  The 
pulse  kept  above  one  hundred  most  of  the  time,  and  the  temperature 
fluctuated  between  100°  and  102°  and  occasionally  103°,  but  this 
high  temperature  never  lasted  long  at  a  time. 

During  the  first  ten  days  the  morphine  was  required,  and  stimu- 
lants had  to  be  used.  In  spite  of  the  frequent  washing  out  of  the 
sac  and  free  drainage  there  was  some  blood-poisoning.  Quinine 
was  freely  given  (whenever  the  temperature  went  up)  by  the  rec- 
tum and  by  inunction.  From  the  twelfth  day  onward  there  was  not 
much  of  interest.  The  patient's  nutrition  was  poor,  the  pulse  and 
temperature  kept  a  little  above  normal,  and  occasionally  the  temper- 
ature rose  to  101°,  rarely  to  102°.  The  sac  cavity  gradually  dimin- 
ished, and  the  discharge  became  less.  At  the  end  of  the  third  week 
the  temperature  was  normal  and  remained  so  afterward.  She  took 
food  well,  and  began  to  gain  strength  and  flesh.  The  cavity  was 
very  small,  and  the  drainage-tube  used  was  a  piece  of  a  No.  10  elas- 
tic catheter.  The  wound  had  completely  healed,  except  where  the 
tube  was  in  place,  at  the  end  of  the  fourth  week. 

Five  weeks  after  the  operation,  and  when  the  patient  was  up 
and  apparently  about  well,  there  came  a  swelling  quite  hard  at  the 
side  of  the  sinus,  and  the  temperature  went  up  to  102°.     It  was  sue- 


ILLUSTRATIVE   CASES   OF   OVARIAN   NEOPLASMS.  541 

pected  that  an  abscess  was  formiug  there,  and  in  the  hope  of  reach- 
ing it,  if  suppuration  occurred,  the  opening  was  enlarged,  and  a 
tube  of  greater  caHber  introduced,  but  the  swelling  entirely  subsided 
and  the  tube  was  removed. 

The  patient  was  discharged  in  good  condition  two  months  after 
the  operation. 

A  Medium-sized  Ovarian  Cyst  which  could  not  be  removed  owing  to 
the  Character  of  the  Adhesions ;  treated  by  Drainage ;  Recovery. — 
The  patient,  a  German  lady,  thirty-four  years  of  age,  was  admitted 
to  the  liospital,  and  gave  the  following  history  :  She  had  had 
several  children  and  had  noticed  a  "  lump  "  in  the  abdomen  about 
one  year  before  my  first  examination.  This  gradually  but  slowly 
increased,  and  at  times  there  was  pain  but  not  severe,  until  about 
four  mouths  after  she  discovered  the  tumor.  At  that  time  she 
was  seized  with  violent  pain  in  the  abdomen,  especially  on  the 
right  side.  According  to  the  history  she  evidently  had  at  that  time 
a  severe  inflammation.  This  slowly  subsided  under  the  care  of  her 
family  physician,  but  she  did  not  regain  her  health,  and  continued 
to  lose  flesh,  her  bowels  were  constipated,  and  there  was  much  pain 
and  tenderness  in  the  region  of  the  tumor.  The  size  of  the  tumor 
increased,  and  it  was  much  more  prominent  on  the  right  side. 

At  my  first  examination,  I  found  the  tumor  firmly  fixed  on  the 
right  side,  the  adhesions  to  the  abdominal  walls  and  viscera  being 
evident  at  all  points,  especially  high  up  in  the  lumbar  region  on  the 
right  side.  The  fluctuation  though  not  clear,  was  sufiiciently  so  to 
indicate  that  the  tumor  was  a  monocyst. 

Her  general  condition  was  very  poor,  she  was  greatly  emaciated, 
her  skin  was  bronzed,  and  she  had  the  general  appearance  of  one 
suffering  from  malignant  disease.  Her  pulse  was  feeble,  and  her 
temperature  varied  between  98°  and  100°.  She  had  pain  and  tender- 
ness in  the  abdomen,  especially  on  moving. 

Efforts  were  made  to  improve  the  general  health,  but  without 
effect.  The  points  of  special  interest  in  the  surgical  treatment  were 
the  following  :  The  abdominal  wall  at  the  point  of  incision  was  very 
vascular,  and  the  adhesions  were  also  thick  and  vascular,  and  were 
with  difiiculty  separated  from  the  cyst-wall.  On  tapping  the  sac  it 
was  found  that  the  contents  contained  lymph  and  some  pus,  show- 
ing that  there  had  been  inflammation  of  the  interior  wall  of  the  cyst. 
On  the  left  side  the  abdominal  wall  was  separated  sufficiently  to  en- 
able me  to  pass  my  fingers  into  the  peritoneal  cavity,  and  there  I 
found  the  intestines  adherent  to  the  cyst-wall.  I  tried  first  to  sepa- 
rate the  adhesions  but  that  could  only  be  done  by  dissection,  and  the 


542  DISEASES   OF   WOMEN. 

bleeding  was  sucli  that  I  had  to  abandon  that  procedure.  I  then  tried 
to  dissect  the  peritona^'iun  olf  from  the  cyst-wall  and  leave  it  attached 
to  the  intestines,  hut  this  was  impossible.  In  a  dissection  about  an 
inch  long  and  half  an  inch  in  width  I  had  to  use  three  ligatures  to 
stop  the  bleeding.  I  also  found  that  every  portion  of  the  sac  was 
fastened  in  by  strong  and  vascular  adhesions  which  I  knew  I  could 
not  separate  without  losing  my  feeble  patient.  The  fact  is  I  could 
not  remove  any  considerable  portion  of  the  sac,  only  a  very  small 
portion  in  front.  I  thoroughly  cleaned  out  the  sac,  and  stitched  the 
edges  to  the  abdominal  wall.  This  was  easily  done  because  the  cyst 
was  adherent  all  round  to  the  abdominal  wall,  except  on  the  left  side. 
A  large  drainage-tube  was  introduced  and  the  sac  washed  out  with 
carbolized  water  twice  or  three  times  a  day. 

The  patient  did  well.     She  began  to  gain  soon  after  the  opera- 
tion, and  continued  to  increase  in  strength  slowly,  but  without  in- 
terruption ;  at  the  end  of  two  weeks  after  the  operation  the  sac  had ' 
contracted  very  nmch,  and  there  was  considerable  suj)puration.    The 
long  tube  w'as  removed,  and  a  shorter  one  was  used  to  maintain  thej 
opening  in  the  abdominal  wall.    The  thorough  washing  out  was  kepf 
up,  and  about  live  times  in  all  I  distended  the  sac  with  ecjual  pari 
of  carbolic  acid  and  tincture  of  iodine.     This  destroys  the  secreting 
surface  of  the  sac,  suppuration  followed,  and  the  sac  contracted  grad4 
ually.     At  the  end  of  two  months  there  was  little  more  left  than 
solid  mass  with  a  narrov/  and  not  very  deej)  sinus  in  it.    The  patient 
was  sent  home,  and  directed  to  wash  out  the  sinus  daily. 

She  was  not  seen  again  until  live  years  after,  when  she  returnee 
to  the  hospital  to  see  my  associate  Dr.  Palmer.  She  had  greatlj 
improved  in  appearance,  and  stated  that  she  had  been  quite  wellj 
and  had  attended  to  her  household  duties  since  she  left  the  hospita 
after  the  operation.  The  opening  in  the  sac  remained  for  foi 
months  after  she  went  home,  but  finally  closed  altogether,  and  gave 
no  trouble  afterward.  She  had  a  ventral  hernia,  which  appeared  a^ 
the  point  of  the  wound  two  years  after  the  operation. 

I  am  satisfied  that  in  certain  cases  in  whioli  the  adhesions  are 
extensive  and  very  vascular  that  it  is  safer  to  leave  the  operatioi 
uncompleted,  and  employ  drainage. 

I  have  had  five  successful  cases  treated  in  this  way,  and  one  vei 
bad  case  that  proved  fatal,  but  probably  would  have  recovered  hac 
the  patient  not  had  organic  disease  of  the  kidneys,  of  which  she  diec 
Mature  judgment,  based  upon  experience  alone,  can  enable  one  to  de 
termine  when  to  employ  drainage  in  place  of  removal  of  the  tumor.1 
The  only  way  to  determine  this  is  to  examine  the  extent  of  thej 


ILLUSTRATIVE   OASES   OF   OVARIAN    NEOPLASMS.         543 

adhesions,  and  whether  or  not  they  can  be  separated  without  injury 
to  the  abdominal  viscera.  Should  the  cyst  prove  unmanageable  by 
tlie  operator,  the  part  of  it  which  can  not  be  removed  should  be  left 
and  treated  by  drainage,  and  washed  out  with  antiseptics.  I  am 
well  aware  that  an  expert  and  experienced  operator  can  manage  very 
formidable  adhesions,  but,  when  an  operator  of  limited  ability  en- 
counters adhesions  that  he  can  not  handle  safely,  he  will  be  more 
sure  of  success  if  he  relies  upon  draining  the  cyst  or  that  part  of  it 
which  can  not  easily  be  removed.  Recovery  is  sometimes  tedious, 
but  generally  sure,  according  to  my  observations. 

The  following  cases  of  suppurating  ovarian  cysts,  reported  by 
Dr.  Keith,  together  with  his  comments  on  them,  are  of  such  great 
value  that  I  cpiote  them  in  full : 


SUPPURATING  OVARIAN   CYSTS. 

The  following  narratives  help  to  show  that  ojDeration  ought  to 
be  the  rule  of  practice  in  cases  of  acute  suppurating  cysts,  or  when 
typhoid  symptoms  come  on  after  tapping : 

Ten  years  ago,  when  cases  of  ovariotomy  were  few,  and  there 
was  little  to  guide  one  in  unusual  circumstances,  a  young  woman  in 
the  last  stage  of  ovarian  disease  came  to  me  a  long  journey  from  the 
north.  The  fatigue  of  traveling  was  too  much  for  the  strength  that 
was  left,  and  she  arrived  completely  worn  out.  It  did  not  seem 
possible  that,  in  such  a  condition,  life  could  be  prolonged  many  days, 
for  the  pulse  was  almost  imperceptible,  there  was  vomiting  and  diar- 
rhoea, oedematous  limbs,  and  albuminous  urine,  while  a  profuse  fetid 
discharge  was  going  on  from  an  opening  near  the  umbilicus.  The 
intensity  of  this  putridity  was  such  that  one  became  aware  of  it 
before  entering  the  house,  and  the  antiseptics  of  those  days  were 
powerless  to  arrest  it.  Day  after  day  I  went  expecting  and  hoping 
to  find  her  dead,  yet,  though  shriveled  up  like  a  mummy,  with  an 
aspect  scarcely  human,  respiration  went  on  for  nearly  a  month,  the 
brain  retaining  its  clearness,  acutely  alive  to  what  was  going  on 
around.  To  remove  a  putrid  cyst  in  such  a  condition  of  feebleness 
did  not  at  that  time  even  occur  to  me  ;  yet,  since  then,  I  have  oper- 
ated more  than  once  under  circumstances  not  less  unfavorable,  and, 
looking  back  upon  this  case  now,  I  think  that  operation  might  have 
turned  out  well ;  certainly  death  after  it  would  have  been  the  more 
merciful  way. 

Soon  again  (December,  1864)  there  came  another  case  of  very 
large  tumor.    The  patient  had  been  jolted  for  some  hours  in  a  coach. 


544  DISEASES  OF  WOMEN. 

and,  in  the  hope  of  relieving  the  pain  thus  set  up,  tapping  was  per- 
formed after  her  arrivaL  The  pain  was  not  relieved,  abdominal 
distention  from  flatus  became  excessive,  and  typhoid  symptoms  rap- 
idly set  it.  Fearing  a  repetition  of  the  slow-death  process — which 
those  who  saw  will  not  easily  forget — ovariotomy  was  this  time  per- 
formed during  the  semi-delirium  of  septic  fever.  This  was  proba- 
bly the  flrst  time  that  surgery  broke  in  upon  an  acutely  inflamed 
peritonaeum.  The  intense  lividity,  amounting  almost  to  blackness, 
of  the  abdominal  contents,  and  the  spongy  tenderness  of  inflamed 
intestine,  were  then  strange  to  me,  though  thought  little  of  now. 
Kecent  lymph  was  present  everywhei-e,  adherent  bowel  and  mesen- 
tery hedged  in  a  thick-walled  cyst,  the  base  of  which  was  in  a  com- 
plete state  of  slough.  Inflammation  had  gone  on  to  gangrene,  and 
there  was  intense  putridity,  just  as  in  the  previous  case.  After  an 
operation  which  went  on  for  two  hours,  the  patient  was  placed  in 
bed,  cold,  vomiting,  and  nearly  pulseless.  It  seemed  as  if  we  had 
simply  killed  her,  yet  she  got  rapidly  into  heat,  the  restless  delirium 
at  once  disappeared,  there  were  warm  perspirations,  much  sleep,  and 
a  recovery  without  a  drawback. 

This  case,  which  was  at  the  time  fully  reported  in  the  "  Lancet," 
1865,  page  480,  has  been  to  me  as  a  landmark.  Since  then  I  have 
ten  times  met  with  cases  of  acute  suppurating  cyst,  besides  two 
chronic  cases.  In  all  of  these,  save  one,  the  chance  of  ovariotomy 
was  given,  however  hopeless  looking  the  case  might  be.  In  the 
exceptional  case  ovariotomy  would  also  have  been  performed  had  it 
been  possible  to  remove  the  patient  from  her  poor  home  and  un- 
favorable surroundings.  She  was  seen  with  Dr.  Menzies  on  the 
third  day  after  her  fourth  conflnement.  He  had  been  called  to  her 
for  the  flrst  time  only  the  day  before.  A  large  ovarian  cyst  had 
existed  with  at  least  two  of  her  pregnancies.  The  distention  was 
so  enormous  that  urgent  dyspnoea  had  to  be  relieved  at  once  by  tap- 
ping. Upward  of  six  gallons  of  fluid,  containing  much  blood  and 
pus,  were  got  away,  and  ovariotomy  was  agreed  on  as  soon  as  she 
could  bear  removal.  This  could  not  be  accomplished,  and,  after 
three  weeks,  tapping  was  again  had  recourse  to.  This  time  the  pus 
was  intensely  putrid,  and,  as  the  cannula  got  choked  with  pieces  of 
fetid  lymph,  an  incision,  suflicient  to  admit  two  fingers,  was  made 
into  the  cyst,  and  its  putrid  contents  thoroughly  cleared  out.  For- 
tunately, the  cyst  was  single ;  a  perfect  recovery  took  place,  and  this 
p&tient  has  had  two  children  since.  None  but  the  strongest  of 
women  could  have  borne  the  exhausting  suppuration  that  went  on 
for  nearly  four  months.    Pulse  and  temperature  remained  high,  and 


ILLUSTRATIVE   OASES   OF   OVARIAN   NEOPLASMS.  545 

of  at  least  six  weeks  of  her  illness  slie  has  now  almost  no  remem- 
brance. Recovery  in  such  circumstances  must  be  rare ;  yet  it  may 
be  well  to  note  that  during  the  whole  time  she  was  supported  en- 
tirely on  milk  and  buttermilk,  and  had  no  stimulants  whatever; 
neither  was  there  any  washing  out  of  the  cyst. 

Of  the  ten  more  or  less  acute  cases  operated  on,  eight  recovered, 
while  the  two  chronic  cases  got  well  easily.  During  1872-'Y3  sev- 
eral came  about  the  same  time,  and  the  following  series  of  seven 
occurred  fn  the  course  of  my  second  hundred  operations  for  ovarian 
tumor,  none  of  which  have  yet  been  published.  To  an  onlooker, 
few  operations  look  so  hopeless  as  those  for  the  removal  of  acute 
suppurating  cysts.  The  general  condition  is  always  unfavorable, 
and,  as  a  rule,  ovariotomy  is  in  these  circumstances  tedious  and  se- 
vere.    To  be  believed  in,  such  cases  need  almost  to  be  seen. 

Suppurating  Ovarian  Cyst;  Ovariotomy;  Recovery. — Mrs.  M., 
aged  thirty-five,  was  sent  to  rae  in  the  end  of  June,  1871,  by  Dr. 
Soutar,  of  Golspie.  An  ovarian  tumor  was  detected  toward  the  end 
of  1869.  In  January,  1870,  she  had  severe  abdominal  pain.  After 
a  fortnight's  rest,  this  passed  off,  but  only  to  return  with  increased 
severity.  Loss  of  flesh  and  rapid  growth  of  the  tumor  followed, 
and  it  was  nearly  a  whole  year  ere  she  was  again  able  to  be  out  of 
bed.  During  this  time  her  sufferings,  as  told  by  a  friend,  must 
have  been  great.  Often  for  weeks  together  she  could  not  be  moved 
from  one  position,  while  the  changing  of  her  dress,  or  the  arranging 
even  of  the  bedclothes,  brought  on  such  pain  that  her  cries  were 
heard  in  the  street.  It  was  eighteen  months  after  her  first  illness 
that  she  was  able  to  make  the  journey  to  town.  I  saw  her  after  she 
had  rested  two  days.  The  pulse  was  then  156 ;  the  temperature 
103°. 

She  was  a  tall,  fair-complexioned,  blanched-looking  woman,  ex- 
tremely emaciated ;  the  lips  and  fauces  were  very  anemic  ;  the  girth 
at  the  umbilicus  was  forty-six  inches ;  the  lower  part  of  the  tumor 
felt  solid,  but  fluctuation  was  distinct  above  the  umbilicus ;  the  ab- 
dominal wall  was  hard,  thickened,  and  oedematous ;  the  skin  even 
in  some  places  feeling  as  if  adherent.  It  was  evident  that  there 
were  adhesions  of  a  very  unusual  nature. 

Two  days  after  this  examination,  with  the  assistance  of  Dr.  Drum- 
mond,  of  Nice,  I  removed  three  gallons  of  thick  pus  by  tapping  some 
inches  above  the  umbilicus.  A  large,  prominent,  hard  tumor  re- 
mained below  this.  Much  relief  followed,  and  for  a  few  days  the 
pulse  and  temperature  somewhat  fell.  In  three  weeks  the  cyst  had 
refilled ;  the  pulse  was  again  rapid  and  feeble,  varying  from  120  to 
36 


546  DISEASES  OF  WOMEN". 

IGO ;  the  morning  temperature  was  101°  to  102°  ;  that  of  the  even- 
ing, 103°  to  10-i°,  sometimes  higher.  The  skin  was  dry  and  shriv- 
eled, and  she  was,  if  possible,  thinner  than  before. 

Ovariotomy  was  performed  on  the  13th  of  July,  1871.  Sul- 
phuric ether  w^as  given.  The  incision  extended  from  the  umbilicus 
downward  eight  inches.  The  wall  was  much  thickened,  the  peri- 
toneum of  almost  cartilaginous  hardness,  and  the  whole  parts  so  un- 
usually vascular,  that  no  time  had  to  be  lost  in  completing  the  oper- 
ation. The  upper  cyst  was  emptied  of  its  purulent  contents,  the 
lower  semi-solid  portion  thoroughly  broken  down,  and  the  cyst- 
walls,  weighing  eighteen  pounds,  dragged  out.  There  was  not  any 
part  of  the  tumor  non-adherent.  The  connections  were  of  the  ut- 
most firmness,  especially  those  in  the  pelvis.  Posteriorly,  there  was 
more  adherent  intestine  and  mesentery  than  I  have  met  with  except 
twice.  The  peritonaeum  was  thickened  by  old  lymph.  Large  flakes, 
like  pieces  of  cartilage,  were  peeled  off  the  wall  after  removal  of  the 
tumor.  Some  of  these  were  as  large  as  the  hand,  and  it  was  difficult 
to  tell  what  really  was  the  peritonaeum.  All  bleeding  points  were 
tied  with  Lister's  ligatures,  a  broad,  thick  pedicle  secured  by  a  clamp, 
and  the  wound  closed  with  silk  sutures. 

The  operation  lasted  upward  of  an  hour ;  much  blood  had  been 
lost,  and  she  was  placed  in  bed  with  great  fears  for  her  immediate 
safety.  She  lay  for  some  hours  with  an  almost  imperceptible  pulse. 
She  was  restless,  and  great  bursts  of  clammy  perspiration  broke  out 
every  now  and  then,  such  as  one  sees  in  those  suffering  from  the 
shock  of  injury.  Fortunately,  there  was  no  vomiting.  By  evening 
she  was  comfortably  warm ;  flatulence  was  troublesome  ;  there  was 
much  thirst.     Pulse,  125  ;  respirations,  32 ;  temperature,  102.° 

She  slept  during  the  night,  but  got  low  and  faint  toward  morn- 
ing, and  there  was  some  vomiting.  Brandy  and  soup  enemata  were 
given  every  two  or  three  hours.  She  improved  toward  evening. 
Flatus  first  passed  forty-four  hours  after  operation.  The  pulse  was 
rapid  and  feeble,  and  she  scarcely  opened  her  lips  for  many  days. 
In  the  third  week  there  was  pain  and  swelling  in  the  right  iliac 
fossa,  and  fluid  formed.  Four  weeks  after  operation  this  swelling 
was  punctured,  and  about  a  teacupf ul  of  yellow  serum  was  removed 
by  a  syringe ;  the  rest  was  absorbed.  She  was  al)le  to  return  home 
in  five  weeks,  and  is  now  a  strong,  healthy  woman. 


CHAPTER  XXX. 

DISEASES    OF    THE    FALLOPIAN    TUBES. 

Before  considering  the  various  morbid  conditions  of  the  Fallo- 
pian tubes,  I  shall  briefly  review  their  anatomy. 

The  tubes — one  on  either  side — are  contained  in  the  broad  liga- 
ments, and  run  transversely  from  each  lateral  corner  of  the  uterus 
out  to  the  ovaries,  to  which  they  are  joined  by  a  short,  ligamentous 
cord.  Each  tube,  or  salpinx,  is  four  to  five  inches  long ;  the  right 
tube  is  usually  slightly  longer  than  the  left.  The  diameter  in- 
creases from  the  uterus  toward  the  ovary ;  and  the  canal  similarly 
increases.  They  are  formed  of  an  external  peritoneal  covering,  of 
an  internal  mucous  surface,  and  of  an  intermediate  proper  muscular 
tissue,  arranged  in  two  layers,  of  which  (1)  the  longitudinal  seems 
to  be  a  prolongation  from  the  uterus  ;  while  (2)  the  circular,  pecul- 
iar to  the  tubes  alone,  ends  as  a  kind  of  sphincter  upon  the  abdomi- 
nal orifice. 

The  mucous  membrane  is  lined  by  cylindrical  epithelium,  the 
motion  of  whose  ciha  is  toward  the  uterus.  Numerous  fusiform 
cells  are  found  in  an  incompletely- developed  connective  tissue.  The 
arteries  arise  from  the  utero-ovarian  trunk,  entering  the  substance 
of  the  tube  at  its  lower  border.  The  veins  empty  into  corresponding 
vessels.     The  nerves  come  from  the  hypogastric  and  ovarian  plexuses. 

A  study  of  the  development,  in  the  embryo,  of  the  female  or- 
gans of  generation,  shows  the  closest  structural  relationships  existing 
between  the  tubes  and  uterus.  Some  observers  claim  that  part  of 
the  menstrual  blood  comes  from  the  tubes. 

Anomalies  of  form  and  situation  are  frequent ;  the  tubes  may 
be  absent ;  there  may  be  only  one  tube  ;  alternate  stenosis  and  dila- 
tation may  exist ;  and  there  may  be  marked  difference  in  length  be- 
tween the  two  tubes. 

Two  abdominal  orifices  for  a  tube  may  exist,  and  fimbria  from 
each  may  project  into  the  peritoneal  cavity. 


54:8  DISEASES  OF   WOMEN. 

Again,  tlie  tube  may  be  dislocated,  twisted,  bent  into  knuckles, 
or  may  have  sulfered  hernia  along  with  portions  of  the  intestine. 
The  tubes  may  open  into  the  womb  abnormally  low  down,  which 
may  possibly  account  for  placenta  ])rievia  in  some  cases. 

The  tube  may  be  completely  separated  from  the  ovary.  A  rare 
condition  is  hernia  of  the  mucosa,  where  the  muscular  tissue  is  ab- 
sent or  so  weak  that  it  allows  the  mucous  membrane  to  protrude, 
forming  a  pocket  into  which  the  fecundated  ovum  may  drop. 

Neoj^lasms  may  be  found  in  the  tubes ;  among  them  tubercle, 
carcinomata,  sarcomata,  cysts,  fibromata,  myomata,  lipomata,  and 
papillomata.  Morgagni's  hydatid  is  a  vesicle  often  hanging  to  a 
fimbria.  Cysts,  tubercles,  and  fibromata  are  the  most  frequent  of 
these  neoplasms,  but  even  these  are  so  rare  that  they  need  only  to 
be  mentioned  here. 

So  many  morbid  tubal  conditions  are  either  direct  or  indirect 
sequelee  of  salpingitis  or  "  catarrh  of  the  tubes"  that  this  condition 
first  demands  attention. 

Salpingitis. — Inflammation  of  the  tubes  may  be  acute  or  chronic. 

Pathology. — In  acute  catarrh  the  mucous  membrane  of  the  tube 
is  thickened,  congested,  and  covered  with  neutral  or  acid  mucus, 
muco-pus,  or  an  opaque  fluid  which  contains  lymph-corpuscles  and 
epithelial  ceils  which  are  changed  in  form  or  which  have  undergone 
granular  degeneration. 

The  longitudinal  folds  of  the  mucosa  are  effaced  ;  the  fimbriae 
are  obliterated  or  obscured  by  inflammatory  products,  and  the  ends  of 
the  tubes  are  usually  closed.  If  not,  the  contents  of  the  tube  enter 
either  the  uterus  or  the  abdominal  cavity  in  which  latter  case  pelvi- 
peritonitis results.  In  very  severe  cases  (and  sometimes  in  diph- 
theria) false  membranes  may  be  formed  in  the  mucosa. 

Peri-salpingitis  usually  occurs  in  severe  cases.  The  tube  is  in- 
creased in  size,  tortuous,  and  dilated  irregularly,  and  when  the  puru- 
lent secretion  accumulates  the  tube  which  is  closed  at  each  end  be- 
comes greatly  distended.  This  is  known  as  pyosalpinx.  In  this 
condition  the  epithelia  are  flattened  and  the  mucous  and  muscular 
coats  are  gradually  thinned,  so  that  rupture  into  the  peritoneal  cav- 
ity is  not  infrequent,  in  which  case  general  peritonitis,  or  pelvi-peri- 
tonitis  results.  In  rare  cases  the  rectum  has  been  perforated  and  the 
contents  of  the  tube  discharged  through  that  viscus. 

Chronic  catarrh  is  accompanied  by  the  adhesions  of  the  tube  to 
the  neighboring  organs  in  some  cases,  the  result  of  localized  perito- 
nitis. The  lower  part  of  the  uterus  is  adherent  oftener  than  other 
adjacent  parts.     The  ovary  is  also  congested  or  inflamed  in  the  ma- 


DISEASES   OF   THE   FALLOPIAN    TUBES.  540 

jority  of  cases.  The  mucosa  is  much  thickened,  and  secretes  a  fluid 
which  is  either  thin  and  watery  or  thick  and  cheesy,  not  purulent  as 
in  acute  salpingitis. 

Occasionally,  chronic  dropsy  of  the  tube  is  the  result  of  the  secre- 
tion of  serous  fluid,  and  the  tube  may  become  distended  and  form  a 
lai'ge  cystic  tumor;  or,  it  may  be  converted  into  several  distinct 
cysts  without  any  intercommunication,  since  the  tube  between  them 
has  been  totally  obhterated  by  the  inflammatory  process. 

This  is  known  as  hydrosalpinx.  In  this  condition  all  the  coats 
of  the  tube  sometimes  become  extremely  thin.  Dropsy  of  tlie 
tube  may  suddenly  terminate  when  an  opening  of  the  duct  into  the 
uterus  occurs  ;  this,  however,  is  very  rare. 

Cases  are  recorded  where  a  hydrosalpinx  has  co:nmunicated  with 
an  enlarged  and  diseased  ovary. 

Symptoms. — This  affection  so  often  follows  gonorrhoea  or  endome- 
tritis that  the  symptoms  of  salpingitis  are  merged  with  those  of  the 
primary  disease  or  are  completely  masked  by  them,  until  pelvic 
peritonitis  occurs.  This  is  the  most  dreaded  outcome  of  salpingitis, 
and  too  frequently  the  first  symptom  which  leads  one  to  suspect  its 
occurrence.  Usually,  however,  when  salpingitis  occurs  there  is  an 
increase  in  the  symptoms  so  marked  as  to  attract  attention.  The 
pain  though  less  pronounced  than  that  of  peritonitis,  is  sufiicient  to 
compel  the  patient  to  rest  in  the  recumbent  position.  There  is  usu- 
ally some  constitutional  disturbance  or  slight  symptomatic  fever.  In 
acute  cases  this  fever  is  well  defined,  and  attended  with  deranged 
digestion  and  nutrition.  In  short,  it  may  be  stated  that  the  local 
and  constitutional  symptoms  are  the  same  as  in  other  pelvic  in- 
flammations, less  acute  than  in  pelvic  peritonitis  or  pelvic  hem- 
atocele, but  as  well  marked  as  in  pelvic  cellulitis  of  a  mild  type. 
When  pyosalpinx  occurs  there  are  symptoms  of  mild  blood-poi- 
soning. 

Menstrual  disturbances  usually  occur  in  salpingitis  but  not  al- 
ways. It  frequently  happens  that  the  severity  of  the  symptoms  is 
lessened,  indicating  that  the  inflammation  has  subsided,  but  it  again 
lights  up,  and  becomes  for  a  time  as  marked  as  at  first. 

Periodical  watery  fluxes  with  diminution  in  the  size  of  a  swell- 
ing in  the  region  of  the  tubes,  and  accompanied  by  colicky  pains, 
are  indicative  of  tubal  dropsy  where  the  tube  is  incompletely  closed 
near  the  uterine  end. 

Physical  Signs. — In  the  first  days  of  the  inflammation  before  the 
tubes  are  distended  the  chief  sign  is  tenderness  in  the  region  of  the 
tubes.     When  a  tumor  can  be  made  out  it  is  felt  to  be  elongated, 


550  DISEASES  OF  WOMEN. 

fluctuatinfi:,  mo%'able,  not  separable  from  the  uterus,  and  lying  on  one 
side  in  the  retro-uterine  space. 

By  aspirating,  a  fluid  which  contains  columnar  ciliated  epithelium 
is  found.  Of  twenty  one  cases  in  which  the  fluid  was  examined 
by  my  colleague  Dr.  F,  Ferguson,  this  epithelium  was  found  in 
nineteen.  This  is  a  most  valuable  diagnostic  sign,  but  as  aspirating 
is  not  witliout  danger  it  should  not  as  a  rule  be  resorted  to. 

Except  when  the  tube  is  enlarged  a  positive  diagnosis  of  salpin- 
gitis can  not  be  made. 

The  condition  with  which  salpingitis  is  apt  to  be  confounded  is 
a  small  ovarian  cyst.  It  is  impossil)le,  often,  to  positively  decide 
this  question  immediately.  By  waiting  and  watching  the  case  the 
ovarian  cyst  will  be  found  to  gradually  become  larger  without  any 
increase  in  the  constitutional  symptoms ;  while  in  tubal  disease  no 
increase  in  size  occurs. 

Prognosis. — I  believe  that  salpingitis  may  subside,  but  as  a  rule 
the  tube  is  obKterated  entirely  or  in  part.  When  hydrosalpinx  oc- 
curs there  is  not  much  chance  of  recovery.  In  pyosalpinx  recov- 
ery can  only  be  insured  by  removal  of  the  tube. 

Causation. — Gonorrhoea  of  the  uterine  mucosa,  and  simple  and 
puerperal  acute  endometritis  are  its  chief  causes ;  but  it  may  occur 
during  the  course  of  any  acute  infectious  disease,  from  the  presence 
of  neoplasms  or  fi"om  intense  hyperaemia  of  the  generative  tract,  as 
in  prostitutes. 

It  is  possible  that  sypbilis  may  cause  it  just  as  it  causes  otitis  or 
ozaena.     Sometimes  it  is  secondary  to  diseases  of  the  ovaries. 

Microbes  may  find  entrance  into  the  tubes,  and  on  this  (not  yet 
proved)  statement,  Sanger,  of  Leipsic,  classifies  salpingitis  as  S.  gon- 
orrhoica,  S.  tuberculosa,  and  S.  actinomycotica.  He  also  bas  a  salpin- 
gitis septica  including  S.  pysemica,  ichorosa,  purulenta,  and  diphthe- 
ritica, which  are  due  to  specific  microbes  identical  with  those  produc- 
ing traumatic  infection. 

Treatment. — Acute  and  subacute  salpingitis,  in  the  early  stages, 
should  be  managed  in  the  same  way  as  other  inflammations  of  the 
pelvic  organs  and  tissues.  Rest  and  anodynes  for  the  relief  of  pain  ; 
counter-irritation  and  attention  to  the  bowels  are  the  chief  indica- 
tions. When  the  acute  symptoms  subside,  iodine  and  mercury 
have  been  used  locally,  and  massage  and  electricity  also,  with  some 
possible  good  results. 

When  once  hydrosalj^inx  or  pyosalpinx  are  developed  it  is  doubt- 
ful if  any  treatment  except  laparo-salpingotomy  is  eifective.  Cer- 
tainly this  is  the  cas2  in  pyosalpinx. 


DISEASES   OF   THE   FALLOPIAN    TUBES.  551 

Laparo-salpingotoniy,  as  linst  ])riicticed  by  Tait  and  Ilegar  is  the 
recognized  treatment  in  these  otherwise  incura])le  diseases  of  the 
tubes,  and  the  results  are  very  satisfactory.  It  is  not  always  possi- 
ble to  ascertain  whether  hydrosal])inx  or  pyosalpinx  exists ;  hence  it 
is  wise  to  perforin  laparotomy  and  remove  the  diseased  tul)e  if  the 
subject  of  pyosalpinx ;  should  a  hydrosalpinx  be  found  it  may  be 
deemed  best  to  try  stripping  the  tubes  or  catheterizing  and  cleaning 
them  out  and  restoring  them  to  their  normal  situation,  and  trasting 
to  curing  the  trouble  thereby.  This  has  been  tried  by  Polk,  but 
the  results  are  not  sufficiently  well  known  to  determine  the  merits 
of  this  procedure.  In  the  former  case  the  woman  is  sterile,  in  the 
latter  not  necessarily  so. 


TUBERCULOSIS    OF    THE    TUBES. 

Pathology. — In  this  condition  the  tubes  are  rigid,  thick,  and 
bound  down  by  pseudo-membranes.  The  thickening  results  from 
infiltration. 

Acute  catarrhal  salpingitis  usually  co-exists.  Both  ends  of  the 
tube  are  usually  closed  but  between  them  the  cavity  is  much  dilated, 
containing  mucus,  muco-pus,  pus,  or  cheesy  debris.  The  vessels  of 
the  tubes  are  enlarged  and  thickened  and  the  nodules  upon  them,  as 
weU  as  the  nodules  on  the  mucosa  and  in  the  muscularis  contain  the 
tubercle  bacillus. 

SyTTijptomatology . — The  tubercular  diathesis  which  is  usually 
present  is  the  only  indication  of  the  nature  of  this  affection.  It  may 
be  possible  to  recognize  the  dilated  tube  by  palpating  the  abdomen, 
and  by  manual  examination  when  its  immobility,  size,  tortuosity,  and 
nodular  feel,  taken  in  connection  with  the  constitutional  conditions 
causes  us  to  suspect  tuberculosis  of  the  tube. 

Possibly  the  dilated  tube  may  be  felt  by  a  vaginal  examination. 
German  gynecologists  advise  that  the  secretions  from  the  uterus 
should  be  examined  for  the  bacilli  which  if  found  are  evidence  of 
tuberculosis. 

Treatment. — Were  it  possible  to  diagnosticate  isolated  tubercu- 
losis of  the  tubes,  extirpation  would  afford  a  means  of  (possible)  radi- 
cal cure. 

HiEMATOSALPINX. 

Blood  in  the  tubes  induces  hypertrophy  of  the  walls  except  at 
one  point,  which,  growing  thinner  and  thinner,  forms  a  sac  varying 
in  size  from  a  pin's  head  to  an  orange.     Any  portion  of  the  tube 


552  DISEASES   OF  WOMEN. 

may  be  the  seat  of  such  a  tumor.  Fatty  degeneration  or  ulceration 
of  the  walls  of  the  tube  may  induce  rupture  and  peritonitis.  At  times 
the  uterine  end  of  the  tubes  permits  of  partial  or  complete  evacua- 
tion of  the  tumor. 

Symptomatology. — The  symptoms  are  the  same  as  those  of  hydro- 
salpinx except  that  they  are  more  acute  at  lirst,  and  at  the  time  of 
the  menses  are  all  markedly  increased  in  intensity. 

Ktioloijy. — Intense  liyperaemia  of  the  genitals,  retroversion, 
typhoid  fever,  measles,  and  purpura  hsemorrhagica  have  been  known 
to  cause  hsematosalpinx.  "When  blood  can  not  make  its  way  out  of 
the  uterus  it  may  flow  back  into  the  tubes.  There  is  no  doubt,  how- 
ever, that  the  mucous  membrane  of  the  tubes  alone  is  capable  of 
being  the  source  of  the  haemorrhage. 

Treatment. — Laparo-salpingotomy  is  the  proper  treatment,  and  if 
the  diagnosis  is  made  the  tube  should  be  removed  before  peritonitis 
occm*s.     The  prospects  of  a  favorable  result  are  then  very  good. 

ILLUSTRATIVE   CASES. 

Salpingitis  imcomplicated ;  Recovery. — The  patient  was  twenty- 
nine  years  old,  and  had  borne  three  children.  She  had  an  endome- 
tritis following  her  last  confinement,  the  cause  of  which  was  probably 
gonorrhoea.  While  under  treatment  for  metritis,  she  became  much 
fatigued,  and  was  exposed  to  cold,  and  soon  after  was  seized  with 
severe  but  not  very  acute  pain  in  the  pelvis,  symptomatic  fever,  loss 
of  appetite,  and  tympanites.  The  temperature  was  101°.  A  digital 
examination  detected  tenderness  in  the  upper  portion  of  both  broad 
ligaments  in  the  region  of  the  Fallopian  tubes.  There  was  no  fixa- 
tion of  the  pelvic  organs,  neither  was  there  any  swelling,  except  that 
the  tubes  could  be  more  distinctly  felt  (by  the  bimanual  touch)  than 
usual. 

The  diagnosis  of  salpingitis  was  made  and  confirmed  by  Dr. 
John  Byrne,  who  saw  the  patient  in  consultation  with  me.  A  mer- 
curial cathartic  was  given,  and  followed  by  a  saline  laxative.  Hot 
applications  were  applied  to  the  abdomen,  and  the  hot-water  douche, 
which  had  been  used  for  her  metritis,  was  continued.  Opium  was 
given  with  bromide  of  sodium  to  relieve  her  pain  and  secure  sleep. 
On  the  fourth  day  from  the  time  of  the  attack  blisters  were  appHed 
over  the  iliac  regions,  the  bowels  were  kept  free  with  saline  laxa- 
tives, and  she  was  kept  at  rest  in  bed.  After  this  the  vaginal  douche 
was  used,  small  doses  of  quinia  were  given  during  the  day,  and  a 
dose  of  bromide  and  opium  at  bed-time.  She  slowly  improved.  At 
the  end  of  two  and  a  half  weeks  she  was  permitted  to  sit  up,  but 


DISEASES   OF  THE   FALLOPIAN   TUBES.  553 

the  dull,  aching,  throbl)ing  pain  returned  in  a  modiiied  degree.  A 
few  days  after  that  her  menstrual  flow  came  on,  and  all  her  symp- 
toms returned  and  continued.  The  flow  was  unusually  free,  and  the 
pain  lessened  as  the  time  passed. 

The  same  line  of  treatment  was  continued,  and  she  recovered 
slowly.  She  was  able  to  be  about,  though  still  easily  fatigued,  and, 
at  the  next  menstrual  period,  she  was  kept  in  bed,  though  she  did 
not  suffer  much.  After  the  menstruation  had  ceased,  1  made  an 
examination  by  the  touch,  and  found  that  the  tenderness  had  gone, 
and  I  resumed  the  local  treatment  of  the  endometritis.  She  recov- 
ered entirely  in  four  months,  but  has  remained  sterile.  It  is  possible 
tliat  we  were  mistaken  in  the  diagnosis,  but  I  am  satisfied  that  we 
were  right. 

Hydrosalpinx ;  Repeated  Discharge  of  the  Contents  of  the  Tube 
through  the  Uterus ;  Recovery. — My  friend  Dr.  William  H.  B. 
Pratt,  called  me  to  see  a  rather  delicate  and  very  refined  lady,  who 
gave  a  history  of  some  rather  obscure  pelvic  affection,  which  had  ex- 
isted for  more  than  a  year.  The  doctor  found,  when  he  was  first 
called  to  see  her,  that  she  had  a  retroversion  of  the  uterus,  and  pre- 
sumed that  this  was  the  whole  cause  of  her  suffering.  He  was  able 
to  restore  the  uterus  to  its  place,  but  could  not  keep  it  in  place,  be- 
cause a  pessary  or  cotton  tampon  caused  great  suffering.  This  was 
the  history  at  the  time  that  I  saw  her.  I  also  learned  that  she  was 
unable  to  ride  or  walk  for  any  length  of  time,  owing  to  the  severe 
pelvic  and  rectal  tenesmus,  which  the  erect  position  brought  on. 
By  a  digital  examination,  I  found  the  retroversion  of  the  uterus,  and 
also  a  cystic  tumor,  low  down  on  one  side  of  the  sac  of  Douglas. 
The  tumor  was  oblong  and  elastic,  and  there  was  distinct  fluctua- 
tion.    I  suspected  that  it  was  an  ovarian  cyst. 

Treatment  gave  her  some  relief,  but  she  did  not  recover.  She 
had  repeated  attacks  of  pain  in  the  pelvis,  and  suffered  so  much  on 
taking  exercise  that  she  was  obliged  to  live  an  invalid  life. 

Some  time  after  seeing  her  the  first  time,  she  menstruated  more 
freely  than  normal,  had  more  pain  and  discomfort  than  usual.  Soon 
after  the  menses  she  had  a  sudden  and  free  discharge  of  fluid  of  a 
whitish,  turbid  character,  and  was  much  reheved  after  it.  I  exam- 
ined her  soon  thereafter,  and  found  that  the  cystic  tumor  had  en- 
tirely disappeared.  Her  symptoms,  though  modified  for  a  time, 
returned  again,  and  again  the  tumor  was  found  in  the  same  place. 
Another  discharge  of  fluid  occurred,  followed  by  relief  and  the  dis- 
appearance of  the  tissues. 

This  much  of  the  historj^,  in  the  way  of  fllling  and  emptying  of 


554  DISEASES   OF   WOMEN. 

tlie  tube,  was  repeated  a  iiuinber  of  times  with  this  difference — that 
the  accumulation  of  fluid  was  less. 

I  regret  that  1  do  not  have  notes  of  the  length  of  time  that  the 
trouble  lasted,  but  it  will  suffice  to  say  that  the  patient  recovered 
completely,  and  has  had  no  return  of  her  hydrosalpinx  of  seven 
years  ago. 

Double  Pyosalpinx ;  Recovery  without  Operative  Interference. — 
The  notes  of  this  case  wei'e  y-iven  to  nie  bv  Dr.  liuckiiiuster.  The 
history  is  a  rare  one,  and  is  of  special  interest.  I  have  in  the  past 
doubted  if  ever  pyosalpinx  ended  in  recovery  withont  removal  of 
the  tubes,  but  this  case  shows  that  such  may  occur.  The  patient 
was  married,  and  twenty-live  years  old.  She  had  an  abortion  pro- 
duced, and  peritonitis  and  salpingitis  followed  this  maltreatment. 
Dr.  Buckmaster  saw  her  two  weeks  after  the  time  of  the  abortion. 
She  was  then  suffering  from  severe  pelvic  inflammation.  The  tem- 
perature was  at  that  time  104°  F.  There  was  marked  pain,  tender- 
ness, and  abdominal  distention.  The  products  of  the  inflammation 
quite  tilled  the  pehnis,  and  there  was  fixation  of  the  uterus.  She 
was  treated  in  the  usual  way  by  the  doctor,  and,  at  the  end  of  two 
months  from  the  time  that  she  first  came  under  his  care,  "  the  in- 
flammatory products  had  largely  disappeared,  and  the  uterus  was 
slifflitlv  movable,  but  on  each  side  there  were  two  masses  about  the 
size  of  small  lemons.  Several  days  afterward  there  was  a  sudden 
discharge  of  ill-smelling  pus.  On  examination  at  this  time  it  was 
foimd  that  the  mass  on  the  left  side  had  disappeared.  Soon  after 
this  there  was  another  free  discharge  of  pus,  and  the  mass  on  the 
right  also  disappeared.  For  three  months  subsequently  there  was  a 
slight  but  constant  discharge  of  jjus  from  the  cervix  uteri,  but  finally 
it  ceased.  Oiie  year  from  the  attack  the  patient  was  in  fair  health, 
but  suffered  from  pelvic  pain  at  times,  which  appeared  to  be  due  to 
adhesions  of  the  peritonitis. 

The  histories  of  many  cases  of  pyosalpinx  might  be  given  in 
which  no  benefit  could  be  obtained  by  general  treatment,  but  were 
promptly  relieved  by  salpingotomy.  In  fact,  the  only  reliable  treat- 
ment for  the  relief  of  this  affection  of  the  tubes  is  to  remove  them. 
The  operation  is  the  same  as  for  the  removal  of  the  ovaries,  and 
need  not  be  described  here.  Those  who  desire  full  details  of  this 
subject  are  referred  to  the  works  of  Lawson  Tait,  whose  brilliant 
achievements  in  this  department  of  surgery  were  the  first  and  greatest. 

No  case  of  haematosalpinx  has  come  under  my  observation,  hence 
the  reader  is  again  referred  to  Lawson  Tait  for  cases  illustrating  this 
subject. 


CHAPTEE  XXXI. 


PELVIO    CELLULITIS. 


The  anatomical  distribiitiou  of  tlie  pelvic  cellular  tissue  is  the 
same  as  that  in  all  other  parts  of  the  body,  and  its  function  in  this 
region  is  also  the  same  as  elsewhere.  It  tills  in  all  the  interspaces 
between  organs  and  tissues,  being  most  abundant  where  there  is  the 
greatest  mobility,  and  it  is  the  principal  accommodating  and  protect- 
ing medium  through  which  the  blood-vessels  and  nerves  are  con- 
veyed to  all  parts  of  the  body. 

In  the  pelvis  it  fills  all  the  unoccupied  spaces  lying  between  the 


yJil.  levator  aui'. 

Fig.  205. — Diagrammatic  transverse  section  of  the  pelvis  (Luschka). 


556  DISEASES   OF    WOMEN. 

pelvic  organs,  except  between  the  peritomeuin  and  tlie  middle  por- 
tion of  the  fundus  uteri.  At  that  point  it  exists  (if  at  all;  in  so 
small  a  quantity  that  it  can  not  be  demonstrated.  Inflammation  of 
the  cellular  tissue  here  located  has  received  many  names — pelvic 
cellulitis,  peri-uterine  cellulitis,  parametritis,  peri-uterine  phlegmon, 
pelvic  abscess,  and  inflammation  of  the  broad  ligaments. 

I  prefer  the  term  pelvic  cellulitis,  which  was  given  to  it  by  Sir 
James  Y.  Simpson  because  it  indicates  the  nature  and  location  of 
tlie  disease.  Inflammation  of  the  cellular  tissue  may  occur  wherever 
that  form  of  tissue  is  found,  hence  the  term  pelvic  cellulitis  does  not 
definitely  locate  the  site  of  the  disease,  and  yet  the  name  is  as  spe- 
cifically descriptive  as  any  of  the  other  terms  used.  Moreover,  pel- 
vic cellulitis,  limited  to  the  areolar  tissue  around  the  cervix  uteri, 
and  between  the  folds  of  the  broad  ligaments,  comes  under  the  ob- 
servation of  the  gynecologist  more  frequently  than  in  any  other 
location  in  the  pelvis ;  hence  it  should  be  understood  that  the  term 
pelvic  cellulitis  is  bere  applied  to  inflammation  of  the  cellular  tissue, 
located  in  the  broad  ligaments  and  about  the  supravaginal  portion 
of  the  cervix  uteri. 

Pathology. — This  differs  in  no  respect  from  inflammation  of 
cellular  tissue  elsewhere,  except  so  far  as  it  may  be  moditied  by  the 
peculiarities  of  the  location.  There  is,  first,  a  stage  of  active  con- 
gestion, followed  by  an  effusion  of  blood  serum,  and  later,  an  exuda- 
tion of  the  higher  organized  constituents  of  the  blood,  and,  finally, 
suppuration. 

In  some  cases  the  inflammatory  process  stops  short  of  suppura- 
tion, and  the  products  of  the  inflammation  are  removed  by  absorp- 
tion, and  tlie  recovery  is  soon  completed.  This  is  called  ending  in 
resolution.  There  are  a  few  cases  in  which  the  products  of  the  mor- 
bid process  are  packed  so  densely  into  the  tissues  that  the  circula- 
tion is  arrested  and  the  cellular  tissue  destroyed,  and  a  dead  mass  or 
slough  is  formed. 

These  cases,  fortimately  rare,  are  very  severe,  and  sometimes  fatal. 
They  are  also  complicated  with  inflammation  of  other  organs  in  the 
pelvis,  as  a  rule.  In  fact,  fatal  cases  are  generally  complicated,  the 
uncomplicated  cases  rarely  proving  fatal. 

When  suppuration  takes  p  ace,  the  pus  usually  makes  its  escape 
by  some  one  of  the  following  avenues,  mentioned  in  the  order  of 
frequency  as  nearly  as  can  be :  Vagina,  rectum,  bladder,  abdominal 
walls,  saphenous  opening,  pelvic  floor  near  the  anus,  pelvic  foramina, 
obturator  or  saero-ischiatic  foramen,  and  through  the  pelvic  roof  into 
the  peritoneal  cavity. 


PELVIC   CELLULITIS. 


557 


T  liave  seen  three  cases  in  which  the  pus  from  an  abscess  in  the 
broad  h'gainent  burrowed  outward  to  the  ihac  fossa,  and  then  ex- 
tended upward  to  the  diaphragm,  and  in  one  it  opened  through  the 
hnig  into  tlie  large  l)roneliial  tube.  Brief  histories  of  these  cases 
will  be  given  at  the  end  of  this  chapter. 

When  the  pus  escapes  into  the  vagina  or  rectum  at  the  most  de- 
pendent part  of  the  abscess  sac,  the  evacuation  is  usually  complete, 
and  the  after-drainage  favorable ;  the  walls  of  the  abscess  come  to- 
gether, and  the  cavity  is  soon  closed.  The  walls  of  the  sac  become 
thin  by  absorption,  the  fixation  and  swelling  of  the  parts  subside, 
and  the  recovery  is  complete. 

In  examining  a  case  in  after  years  that  I  had  treated  for  cellulitis, 
I  found  that  all  traces  of  the  disease  had  disappeared,  so  far  as  could 
be  ascertained  by  physical  exploration,  and  the  functions  of  the  pel- 
vic organs  were  all  performed  normally,  thus  showing  that  the  recov- 
ery was  complete.  This  is  the  history  of  the  pathology  of  the  sim- 
plest cases  of  pelvic  cellulitis. 

When  the  pus  escapes  into  any  other  pelvic  viscera  at  a  point 
above  the  most  dependent  part  of  the  abscess  sac,  the  evacuation  is 
necessarily  incomplete,  and  the  drainage  imperfect.  Chronic  sup- 
puration and  discharge  will  occur  under  such  circumstances,  and  the 
duration  of  the  case  is  very  indefinite.  This  is  often  the  result 
when  the  point  of  escape  is  through  the  abdominal  walls  or  the  pel- 
vic foramina ;  but  the  same  thing  occurs  sometimes  when  the  open- 
ing is  into  the  vagina  or  rectum  or  bladder,  especially  the  rectum. 

Judging  from  several  cases  that  I  have  seen,  in  which  the  open- 
ing was  into  the  rectum,  I  am  inclined  to  believe  that  the  direction 


Fig.  206. — Pelvic  abscess  opening 
obliquely  downward. 


Fig.  207. — Pelvic  abscess  opening 
obliquely  upward. 


of  the  opening  has  something  to  do  with  keeping  up  the  suppuration. 
When  the  opening  is  low  down,  and  enters  the  rectum  obliquely 
downwai'd,  and  the  drainage  is  complete,  the  opening  will  close 


558  DISEASES   OF    WOMEN. 

promptly  (Fig.  200);  but,  if  the  opening  into  the  rectum  is  direct  or 
obliquely  upward,  tlie  contents  of  tlie  bowels  will  escaj)e  into  the 
abscess  sac,  and  keep  up  suppuration  for  an  indefinite  length  of  time 
(Fig.  207). 

These  conditions  in  the  pathology  of  cellulitis  afford  a  reasonable 
explanation,  perhaps  the  true  one,  of  the  difference  in  progress  be- 
tween cases  that,  up  to  the  time  of  evacuation  of  pus,  appeared  to  be 
alike. 

.  There  is  yet  another  condition  in  tlie  morbid  products  of  the 
disease  which  retards  recovery.  In  place  of  the  suppurative  pro- 
cess, involving  the  whole  mass  of  inllammatory  products,  a  number 
of  small  abscesses  are  found  producing  a  honey-comb  state  of  the 
parts,  a  number  of  small  abscesses  opening  into  each  other  by  small 
sinuses,  and  all  opening  into  some  of  the  pelvic  viscera,  by  one  or 
more  openings.  This  pathological  condition  delays  the  progress  of 
the  case  greatly.  All  these  exceptional  peculiarities  in  the  pathology 
which  complicate  the  progress  of  the  disease  also  tend  to  make  the 
after-effects — i.  e.,  the  damage  to  the  pelvic  organs — greater.  The 
walls  of  the  abscess  are  thicker,  and  the  scar  left  in  the  tissue  contracts 
more,  and  hence,  displacements  are  often  found.  Pelvic  pains  of  a 
neuralgic  character  often  follow,  and  the  functions  of  the  pelvic  organs, 
uterus,  rectum,  and  bladder  are  to  some  extent  occasionally  deranged. 

There  is  still  another  form  of  behavior  noticed  in  some  cases. 
Suppuration  takes  place  at  one  point,  usually  a  small  one,  and  instead 
of  the  pus  escaping  in  the  usual  manner,  it  finds  its  way  into  the 
circulation  causing  septicaemia,  which  is  intermittent  in  character. 
The  temperature  and  pulse  run  up  high  for  a  time  and  then  sub- 
side, the  fever  being  sometimes  preceded  by  a  chill  or  rigor.  These 
paroxysms  are  repeated  over  and  over  again,  the  general  nutrition 
of  the  patient  being  greatly  impaired. 

The  chief  cause  of  pelvic  cellulitis  is  septicaemia,  and  is  usually 
traumatic  in  its  origin.  Injuries  to  the  uterus  and  vagina  during 
parturition  or  abortion  develop  septic  material  which  is  conveyed  to 
the  cellular  tissue  by  absorption  through  the  lymphatics  pi-iucipally. 

It  is  possible  that  lymphangitis  is  primarily  developed,  and  sub- 
sequently, cellulitis.  Be  this  as  it  may,  the  fact  is  that  two  thirds  of 
all  the  cases  occur  after  abortion  or  parturition.  Whenever  cellulitis 
follows  parturition,  it  may  be  presumed  that  it  is  caused  by  the  absorp- 
tion of  septic  material  from  the  parturient  canal.  It  is  possible,  how- 
ever, that  contusions  of  the  cellular  tissue  occurring  during  parturi- 
tion may  give  rise  to  decomposition  of  the  injured  tissue  and  septic 
cellulitis,  which,  in  that  case,  is  autogenetic,  and  not  due  to  absorption. 


PELVIO   CELLULITIS.  559 

The  other  and  far  less  common  causes  of  cellulitis  arc  surgical 
operations,  the  use  of  caustics,  ill-fitting  pessaries,  dilatation  of  cervix 
uteri  with  sponge  tents  and  direct  blows,  but  with  all  of  these  the 
cause  is  septic,  the  morbid  material  being  developed  by  the  injury. 

Cellulitis  occasionally  occurs  secondarily  to  some  pre-existing  in- 
flammation, such  as  endometritis,  pelvic  peritonitis,  saljiingitis,  and 
ovaritis.  These  last-named  aifections,  when  they  precede  the  cellu- 
litis, stand  in  a  causative  relation  to  it.  It  quite  frequently  hap- 
pens, however,  that  the  above-named  diseases  are  developed  in  the 
course  of  a  cellulitis,  and  are  caused  by  it,  and  hence  become  com- 
plications of  the  cellulitis. 

The  duration  of  cellulitis  varies  very  much  according  to  the  ex- 
tent of  the  inflammation,  but  more  especially  is  the  progress  modi- 
tied  by  the  termination  of  the  inflammatory  process.  In  case  that 
resolution  takes  place,  recovery  may  occur  in  a  few  weeks,  but  on 
the  other  hand,  if  suppuration  occurs  and  the  discharge  of  pus  is 
incomplete,  owing  to  the  unfavorable  point  of  escape,  then  chronic 
suppuration  may  go  on  for  months  or  years. 

When  suppuration  takes  place  and  the  discharge  of  pus  is  at  the 
dependent  part  of  the  abscess,  the  average  duration  of  the  disease 
is  about  six  weeks.  Much  has  been  said  about  chronic  cellulitis,  but 
I  have  never  been  able  to  recognize  any  such  condition.  Chronic 
suppuration  in  a  badly-drained  abscess  may  go  on  for  any  length  of 
time — this  we  often  see  ;  also,  frequent  or  repeated  attacks  of  cellu- 
litis may  occur,  but  a  chronic  or  continuous  inflammation  such  as 
we  see  in  inflammation  of  mucous  membranes,  is  something  which  I 
have  never  met  with  in  practice.  This  is  quite  in  accord  with  what 
we  know  of  cellulitis  elsewhere,  where  the  process  begins,  pro- 
gresses, and  ends  and  recovery  follows,  or,  it  may  be,  that  the  inflam- 
mation progresses  to  the  stage  of  suppuration,  and  for  some  reason 
suppuration  is  kept  up,  but  this  is  simply  a  chronic  condition  of  one 
stage  of  the  process. 

I  think  that  the  so-called  chronic  cellulitis,  recognized  and  treated 
as  such  by  some  authorities,  is  nothing  more  than  the  products  of 
the  inflammation  which  remain  after  the  inflammation  itself  has 
subsided. 

The  consequences  of  pelvic  cellulitis  depend  largely  upon  the 
extent  of  the  tissue  involved  and  the  quantity  of  inflammatory  exu- 
date. Sometimes,  the  tissues  become  infiltrated  with  the  products 
of  the  inflammation  which  do  not  all  break  down  in  the  suppurative 
process  ;  when  this  occui'S,  it  requires  a  long  time  to  efiiect  the  absorp- 
tion of  these  products,  and  during  that  time,  the  patient  is  likely  to 


560  DISEASES   OF   WOMEN". 

suffer  from  derangement  of  tlie  functions  of  the  pelvic  organs  and 
also  from  pelvic  pain.  So,  also,  when  the  products  of  the  inflamma- 
tion have  all  been  disposed  of,  if  much  damage  has  been  done  to  the 
tissues,  which  is  usually  the  case,  contractions  follow  which  are  apt 
to  displace  the  pelvic  organs  to  some  extent,  and  to  give  rise  to 
trouble ;  and  yet,  in  the  majority  of  uncomplicated  cases  of  cellu- 
litis, complete  and  perfect  recovery  generally  takes  place.  This,  I 
have  frequently  been  able  to  verify  by  subsequent  examination  of 
cases  that  I  have  formerly  treated.  More  than  that,  it  not  infre- 
quently happens  that  patients,  after  a  well-detined  cellulitis,  recover 
and  bear  children,  showing  conclusively  that  the  recovery  was  com- 
plete and  perfect. 

In  the  clinical  history  of  pelvic  cellulitis,  as  manifested  by  the 
symptoms  and  physical  signs  presented,  there  is  a  great  variation  in 
different  cases  ;  just  as  the  extent  of  the  local  lesions  differ  in  degree 
and  extent,  so  the  symptoms  vary  in  their  severity.  There  is  usu- 
ally a  decided  symptomatic  fever  as  indicated  by  the  frequency  of 
pulse  and  elevation  of  temperature.  This  may,  or  may  not  be  pre- 
ceded by  a  chill  or  rigor  which  is  promptly  followed  by  fever. 

The  temperature  as  a  rule  is  not  high,  from  101-|°  F.  to  103°  F. 
being  about  the  range.  There  is  also  marked  derangement  of  the 
digestive  organs ;  sometimes,  there  is  some  nausea  and  vomiting, 
almost  always  tympanitic  distention  of  the  bowels,  and  usually  con- 
stipation. It  is  rare  that  there  is  any  delirium  or  very  marked  de- 
pression of  the  nervous  system.  The  patient  usually  complains  of 
pain,  the  intensity  of  which  varies  considerably ;  it  is  usually  most 
marked  in  the  rare  cases  which  arise  from  causes  other  than  parturi- 
tion at  the  full  term. 

When  the  cellulitis  follows  delivery,  there  is  abundant  room  for 
the  products  of  the  inflammation  in  the  cellular  tissues  of  the  largely 
developed  broad  ligaments,  and  so  the  pain  which  is  usually  caused 
by  pressure  of  these  products,  is  not  so  great.  In  other  cases  due  to 
injuries,  intercellular  haemorrhages,  and  the  like,  the  tissues  resist 
the  distention  and  the  exudation,  and  hence  the  pain  is  much  greater, 
and  there  is  usually  decided  disturbance  of  the  function  of  the  pel- 
vic organs. 

If  the  attack  comes  on  when  the  menstrual  period  is  near  there 
may  be  a  menorrhagia.  There  is  also  quite  often  vesical  and  rectal 
tenesmus.  There  is  tenderness  on  deep  pressure  in  the  iliac  regions, 
and  the  pain  is  usually  aggravated  by  any  movement  on  the  part  of 
the  patient.  This  usually  compels  the  sufferer  to  rest  quietly  on  the 
back.     Occasionally,  some  relief  is  obtained   by  drawing  up  the 


PELVIC  CELLULITIS.  561 

limbs  while  resting  on  the  back,  but  this  position  is  not  by  any  means 
as  frequently  assumed  and  persistently  maintained  as  in  peritonitis. 
These  symptoms,  both  general  and  local,  usually  continue  without 
much  modification,  except  that  relief  which  may  be  obtained 
through  the  influence  of  medication,  until  the  exudation  is  com- 
pleted ;  then  there  is  usually  a  lowering  of  the  temperature  and 
pulse,  and  relief  from  pain.  The  temperature,  however,  usually  re- 
mains above  100°  F. 

When  suppuration  begins,  there  is  a  renewal  of  the  symptomatic 
fever;  sometimes  a  chill  precedes  this  recurrence  of  fever.  On  the 
other  hand,  if  resolution  takes  place,  the  fever  does  not  return  to 
any  very  great  extent.  During  the  suppurative  process  until  the 
time  when  the  pus  is  discharged,  the  temperature  remains  usually 
above  100°  F.,  sometimes,  suddenly  running  up  to  103°  F.,  indicat- 
ing that  there  may  be  a  little  acute  septicaemia.  When  the  abscess 
opens  and  is  completely  emptied,  there  is  usually  a  prompt  and  al- 
most complete  relief  from  the  symptomatic  fever. 

In  case  that  the  pus  remains  imprisoned  or  .is  only  partially  evac- 
uated, and  the  suppuration  and  discharge  continue  to  go  on,  there  is 
usually  marked  constitutional  disturbance,  manifested  by  high  tem- 
perature which  varies  abruptly  in  degree ;  at  times  running  down 
almost  to  normal  and  again  going  up  to  104°  F.,  or  to  104^°  F. 

Physical  Signs. — These  necessarily  differ  according  to  the  stage 
of  progress  of  the  inflammation.  During  the  stage  of  engorgement, 
a  digital  examination  usually  detects  only  swelling  of  the  parts  and 
tenderness  on  pressure,  and  if  the  examiner's  sense  of  touch  is  very 
acute,  increased  heat  may  be  detected ;  any  effort  to  move  the 
pelvic  organs  will  usually  cause  pain.  When  the  exudation  takes 
place,  the  touch  detects  marked  induration  of  the  parts  involved, 
and  when  it  is  complete,  a  well-defined  tumor  in  both  broad  liga- 
ments will  be  found,  or  it  may  be  that  this  njass  is  found  on  either 
side  of  the  cervix.  K  the  tenderness  when  pressure  is  made  upon 
the  abdominal  walls  is  not  great,  and  there  is  not  much  tympanitic 
distention,  the  tumor  can  sometimes  be  accurately  outlined  by  the 
bimanual  examination.  Usually,  however,  not  much  can  be  accom- 
plished in  this  way  because  of  the  distention  of  the  abdominal 
walls  and  the  tenderness  on  pressure  there. 

The  size  of  the  tumor  of  course  depends  upon  the  extent  of  the 
exudation ;  in  some  cases  it  is  not  lai'ger  than  a  small  orange,  in  oth- 
ers, both  broad  ligaments  may  be  split  up,  and  so  filled  wnth  the 
exudate  as  to  extend  above  the  true  pelvis  and  come  in  contact  with 
the  abdominal  walls,  so  that  the  mass  can  be  easily  identified  by  ab- 
37 


562  DISEASES   OF   WOMEN. 

dominal  palpation.  This  I  have  seen  in  but  one  case,  though  I  have 
frequently  seen  the  tunior  on  one  side  large  enough  to  be  distin- 
guished in  this  way. 

The  extension  of  the  tumor  upward  out  of  the  true  pelvis,  is 
much  more  frequently  seen  in  cellulitis  following  labor,  and  it  is  a 
physical  sign  characteristic  of  cellulitis  as  compared  with  pelvic  peri- 
tonitis. 

When  the  tumor  occurs  on  one  side,  there  is  usually  displace- 
ment of  the  uterus,  that  organ  being  pushed  in  the  opposite  direc- 
tion. When  both  broad  ligaments  are  involved,  the  uterus  may  be 
carried  ujDward  and  forward.  In  cases  occurring  in  the  non-puer- 
peral state,  the  uterus  is  often  crowded  somewhat  downward  ;  in  all 
cases  there  is  most  marked  induration  of  the  parts  presented  to  the 
digital  touch,  and  also  fixation  of  the  uterus.  When  i-esolution  ter- 
minates the  case,  a  gradual  diminution  of  the  tumor  will  be  observed 
from  time  to  time.  When  suppuration  and  evacuation  take  place, 
there  is  a  more  prompt  reduction  in  the  size  of  the  mass. 

The  physical  signs  sometimes  change  when  suppuration  occurs, 
but  it  is  exceedingly  difficult  to  detect  the  presence  of  pus  in  this 
location,  although  it  is  often  important  to  do  so.  It  is  usually  im- 
possible, also,  to  detect  fluctuation,  because  the  abscess  can  not  be 
touched  at  two  points  far  apart.  One  must  rely  then  upon  the  soft- 
ening of  the  mass  as  felt  by  the  index-finger,  as  the  sign  of  suppu- 
ration. 

This  is  liable  to  be  simulated  by  oedema  of  the  abscess-wall,  but 
this  can  readily  be  distinguished  by  observing  that  the  parts  pit  on 
pressure.  It  often  happens,  however,  that  one  can  not  decide  re- 
garding the  presence  of  pus,  and  if  it  is  of  great  importance  to  so 
determine,  the  aspirating-needle  should  be  employed. 

Treatment. — During  the  first  stage  of  cellulitis,  treatment  should 
be  employed  with  the  view  of  controlling  the  inflammatory  process, 
and,  if  not  able  to  abort  the  trouble,  to  limit  or  circumscribe  it  as 
far  as  possible.  To  accomplish  this,  perfect  rest  should  be  enjoined, 
and  all  pain  relieved  or  made  tolerable  by  the  use  of  opium.  The 
opium  should  be  given  by  the  mouth  in  doses  sufficient  to  give  re- 
lief, and  be  repeated  often  enough  to  maintain  that  relief.  In  case 
the  stomach  is  so  irritable  as  to  refuse  the  opium,  then  it  should  be 
administered  hypodermically. 

There  is  at  the  present  day  some  belief  that  quinine  given  in 
large  doses  often  controls  or  modifies  local  and  inflammatory  action ; 
this  appears  to  be  so  in  some  specific  inflammations  like  pneumonia, 
and  it  possibly  may  have  some  such  controlling  influence  in  cellulit- 


PELVIC   CELLULITIS.  563 

is ;  if  the  stomacli  will  admit  of  it,  no  harm  can  come  from  giving 
ten  or  fifteen  grains  of  quinine  in  a  day  at  the  outset  of  pelvic  cel- 
lulitis, and  possibly  mucli  good  may  result.  Opium,  however,  is 
the  chief  agent  when  there  is  much  pain  or  restlessness  in  the  first 
stage ;  the  opium  not  only  reheves  the  pain  but  also  keeps  the  bow- 
els at  rest,  which  is  quite  desirable ;  the  bowels,  however,  should 
not  be  kept  too  long  confined ;  in  fact,  I  make  it  a  rule  when  a  case 
is  seen  early,  and  the  rectum  is  distended,  to  empty  it  by  means  of 
a  mild  enema,  then  the  bowels  should  be  kept  quiet  until  the  tem- 
perature and  pulse  come  down  and  the  pain  subsides,  when  the  bow- 
els may  be  again  moved  by  enema ;  this  secures  one  evacuation  be- 
tween the  stage  of  exudation  and  suppuration. 

Local  applications  sometimes  give  the  patient  a  certain  amount 
of  comfort,  and,  when  such  is  the  case,  there  should  be  employed 
warm  poultices,  or,  better,  flannels  wrung  out  of  hot  water,  and  cov- 
ered mth  oil-silk. 

The  exudation  may  be  limited  to  some  extent,  it  is  claimed  by 
some  authors,  by  the  use  of  counter-irritants ;  this,  I  think,  is  doubt- 
ful ;  therefore,  if  they  are  used  at  all,  the  milder  agents,  like  mus- 
tard paste,  may  be  employed.  During  all  this  time  the  patient 
should  be  nourished  as  well  as  possible.  If  a  vigorous  subject,  less 
care  in  the  way  of  diet  is  necessary ;  but,  if  feeble,  an  abundance  of 
nourishing  food  should  be  offered.  Prof.  Yirgil  O.  Harden,  M.  D., 
of  Atlanta,  Georgia,  has  practiced  aspiration  with  good  results  in 
the  stage  of  serous  infiltration.  A  case  illustrating  this  mode  of 
treatment  will  be  given  hereafter. 

When  suppuration  occurs,  the  majority  of  patients  will  bear  at 
that  time  sustaining  means,  nourishing  food,  full  doses  of  quinine, 
and,  in  some  cases,  stimulants.  To  sustain  the  patient  is  the  chief 
object  at  this  stage. 

If  the  case  promises  to  end  in  resolution,  that  should  be  favored 
by  counter-irritants,  and  the  internal  use  of  the  preparations  of  iodine 
combined  with  tonics.  When  the  abscess  opens,  and  discharge  fol- 
lows, sustaining  measures  are  all  that  is  necessary. 

If  suppuration  takes  place,  and  the  pus  is  not  discharged,  l)ut  is 
retained,  and  causes  septicaemia,  it  should  be  removed  by  aspiration, 
and  this  operation  repeated  if  need  be.  If  the  accumulation  occurs 
again  and  again  after  aspiration,  the  sac  should  be  more  freely  opened 
and  drained  through  the  vagina. 

When  the  drainage  is  incomplete,  because  of  the  opening  being 
too  high  up,  an  opening  should  be  made  at  the  most  dependent  part, 
and  the  drainage-tube  inserted.    In  case  that  the  imprisoned  pus  can 


564  DISEASES   OF   WOMEN. 

not  be  reached  tlirongli  the  vagina,  and  the  patient's  life  is  in  danger 
from  chronic  sup])uratiou  or  septicaemia,  the  practice  of  Lawson  Tait 
may  be  adopted — that  is,  opening  the  abdominal  wails,  and  draining 
the  abscess  with  a  drainage-tube  in  the  abdominal  wound. 

The  operation  of  opening  the  abdominal  walls,  and  indirectly 
draining  a  pelvic  abscess,  involves  all  the  difficulties  and  dangers  of 
laparotomy.  It  is  a  very  diiferent  thing  when  the  abscess  sac  is 
adherent  to  the  abdominal  wall.  Making  an  opening  at  the  adher- 
ent point,  and  draining  the  sac,  is  little  more  than  opening  an  or- 
dinary abscess. 

These  are  the  principal  points  in  the  treatment  of  cellulitis ; 
other  details  of  the  clinical  history  and  treatment  will  be  brought 
out  in  the  history  of  cases. 

ILLUSTKATIVE   CASES. 

A  Case  of  Cellulitis  uncomplicated,  ending  in  Suppuration. — When 
this  patient  was  twenty-six  years  old  she  gave  birth  to  her  second 
child.  Tlie  labor,  for  some  reason  unknown  to  me,  was  tedious,  and 
her  physician  delivered  her  with  forceps.  She  progressed  fairly 
well  until  the  fourth  day,  when  she  had  a  chill,  followed  by  fever, 
her  temperature  running  up  to  100°  and  102|^°.  She  also  had  pain 
in  the  pelvis  and  distention  of  the  abdomen,  but  the  lochia  and  milk  , 
secretion  continued,  although  in  diminished  quantity.  Her  general 
condition  remained  about  the  same,  except  that  she  obtained  relief 
from  opium  given  by  her  physician  until  four  days  afterward.  At 
that  time  I  saw  her,  and  found,  on  examination,  a  large  mass  on 
the  left  side,  filling  the  upper  portion  of  the  pelvis,  pushing  the 
uterus  to  the  right,  and  extending  above  the  superior  strait,  so  that 
I  could  distinctly  make  it  out  through  the  abdominal  walls.  This 
mass  was  so  closely  united  to  the  uterus  that  it  appeared  to  be  a  part 
of  that  organ,  but  was  as  large  as  the  uterus  itself.  There  was  ten- 
derness to  the  touch,  marked  induration,  and  yet  the  mass  and  the  ; 
uterus  were  very  slightly  movable.  Pain  at  this  time  was  not  great, 
and  the  patient  only  complained  of  a  little  local  distress  and  discom- 
fort, and  said  that  she  felt  weak.  At  the  same  time,  her  pulse  and 
temperature  were  both  above  100. 

There  was  also  laceration  of  the  cervix  uteri,  and  the  discharge 
was  muco-purulent.  At  this  time  she  had  very  little  nourishment 
for  her  child,  and  yet  there  was  a  little.  She  was  directed  to  have 
perfect  rest,  nourishing  food,  opium  sufficient  to  keep  her  free 
from  pain  and  to  secure  comfortable  nights,  with  tonic  doses  of 
quinine. 


PELVIC   CELLULITIS.  565 

The  disinfecting  vaginal  douche  which  had  been  used  was  con- 
tinued ;  tonic  doses  of  quinine,  with  fluid  extract  of  ergot,  were  or- 
dered three  times  a  day,  and  turpentine  stupes  were  directed  to  be 
applied  to  the  abdomen.  One  week  later  I  saw  lier  again  in  consul- 
tation, and  learned  from  her  attendant  that  but  little  change  had 
taken  place  in  her  condition  ;  the  temperature  was  lower,  her  appe- 
tite had  improved,  there  was  ahiiost  no  pain,  and  she  felt  stronger. 
On  examination,  there  was  little  if  any  change  in  the  tumor,  the 
physical  signs  being  about  the  same ;  the  local  discharge  still  con- 
tinued, but  was  less  purulent  and  offensive  ;  the  surface  temperature 
varied  from  time  to  time ;  occasionally  the  skin  was  hot ;  at  other 
times  there  was  free  perspiration.  It  was  impossible  at  this  time  to 
detect  the  presence  of  pus  in  the  mass  in  the  palvis.  Five  days 
afterward  I  saw  her  again,  when  I  learned  that  she  had  had  a  chill, 
followed  by  a  rise  of  temperature  and  pulse ;  she  had  also  suffered 
from  rather  profuse  sweating.  At  this  time  her  general  appearance 
was  less  satisfactory ;  she  had  a  somewhat  dusky  hue  of  face,  the 
pulse  also  was  not  as  strong,  and  the  milk  had  stopped  entirely. 
Just  before  the  chill  her  bowels  had  been  moved  by  enema,  and 
both  patient  and  physician  were  disposed  to  attribute  the  increase  in 
her  trouble  to  the  effect  of  the  enema,  but  it  undoubtedly  was  due 
to  suppuration  having  begun. 

On  examination,  the  mass  was  felt  to  be  softer  at  the  most  de- 
pendent part,  and  yet  no  distinct  flexion  could  be  made  out.  Qui- 
nine was  given  in  somewhat  larger  doses,  the  vaginal  douche  was 
continued,  and  a  little  wine  was  added  to  the  bill  of  fare. 

A  few  days  after  this  her  pulse  and  temperature  improved  con- 
siderably. She  had  then  very  little  pain,  but  a  sense  of  heat,  full- 
ness, and  dull  aching  in  the  pelvis.  Four  days  after  this  there  was 
a  copious  discharge  of  pus  from  the  vagina,  followed  by  marked 
improvement  in  the  pulse,  temperature,  and  general  condition.  The 
day  following  a  marked  diminution  in  the  size  of  the  tumor  was 
noticed  ;  there  continued  to  be  a  discharge  of  pus  in  diminishing 
quantity  for  nearly  a  week,  but  during  that  time  she  improved  in 
general  condition  very  decidedly.  The  mass  gradually  diminished, 
and  the  uterus  also  progressed  in  involution,  and  her  strength  re- 
turned, so  that  she  became  anxious  to  get  up.  She  was  kept  quiet, 
however,  for  some  time,  until  involution  was  complete,  and  all  that 
remained  of  the  inflammation  was  a  small,  hard,  but  not  tender  mass 
on  the  left  side  of  the  uterus  and  in  the  broad  ligament,  evidently 
the  collapsed  or  the  contracted  walls  of  the  abscess. 

From  this  time  onward  the  improvement  was  steady  and  unin- 


5G6  DISEASES  OF  WOMEN. 

terrupted,  and  she  was  soon  able  to  resume  her  duties,  with  tlie 
exception  of  nursing  her  child.  At  the  end  of  two  months  from 
the  tirue  of  the  attack,  she  was  quite  well,  and  no  traces  of  lier 
trouble  remained  except  a  decided  thickening  of  the  broad  liga- 
ment. 

A  Case  of  Cellulitis,  ending  in  Resolution ;  the  Cause  Dilatation  of 
the  Uterine  Canal  by  Sponge  Tent  preparatory  to  curetting. — A  hidv 
twenty-eight  years  of  age,  who  had  been  married  seven  years,  had 
suffered  for  some  tinie  with  menorrhagia,  caused  by  fungosities  of 
the  endometrium,  and,  although  the  cervical  canal  was  quite  empty, 
it  was  deemed  necessary  to  dilate  the  canal  with  a  si^onge  tent  before 
removing  the  fungous  growths.  The  sponge  tent  was  introduced 
late  in  the  evening,  and  remained  during  the  following  forenoon ; 
the  curette  was  used  immediately  afterward,  and  the  abnormal 
growths  completely  removed.  Twenty-four  hours  after  this  she 
began  to  liave  pain  in  the  region  of  the  left  broad  ligament,  at  the 
same  time  developing  sjTnptomatic  fever,  the  temperature  running 
u])  to  l(»li°  F.,  and  the  pulse  being  accelerated.  She  also  had  a 
little  nausea  when  the  pain  was  most  severe,  with  loss  of  appetite 
and  some  tympanitic  disturbance  of  the  bowels.  On  digital  exam- 
ination, made  three  days  subsequently,  a  somewhat  ill-detined  mass 
was  found  in  the  right  broad  ligament,  which  increased  during  the 
following  forty-eight  hours  until  it  attained  the  size  of  a  hen's  egg. 
There  was  a  little  displacement  of  the  uterus  to  the  right,  but  very 
little.  This  mass  was  quite  tender  to  the  touch,  and  could  not  be 
moved ;  neither  could  the  utenis  be  moved  without  causing  acute 
pain.  Opium  was  given  to  relieve  the  pain,  and  the  boweLs  were 
allowed  to  remain  constipated  for  about  four  days.  A  vaginal  douche 
of  borax  and  warm  water  was  used  twice  daily,  removing  a  muco- 
sanguinolent  discharge.  The  pain  gradually  subsided,  and  at  the 
end  of  four  or  five  days  the  bowels  were  moved ;  the  fever  also  di- 
minished, the  appetite  slowly  returned,  and  about  this  time  the  mass 
began  to  slowly  diminish  in  size.  At  the  end  of  two  weeks  the  pa- 
tient was  permitted  to  leave  her  bed  and  sit  in  her  chair,  but  was 
not  allowed  to  take  any  active  exercise  until  after  the  next  menstrual 
period.  During  that  time  she  was  confined  to  her  bed,  fearing  that 
the  inflammatory  process  might  again  be  lighted  up.  After  the 
period,  which  lasted  about  five  days,  she  was  permitted  to  resume 
her  duties  gi*adually,  but  was  directed  to  rest  quietly  at  the  next 
menstrual  period,  which  she  did.  Afterward,  on  examination,  it 
was  found  that  the  mass  in  the  broad  ligament  had  wholly  disap- 
peared, there  was  no  tenderness  and  no  evidence  of  congestion  or 


PELVIC   CELLULITIS.  5G7 

any  other  trouble,  and  her  subsequent  history  sliows  recovery  to  have 
been  complete. 

I  am  quite  sure  that  the  diagnosis  in  this  case  was  correct,  and 
1  am  also  satisfied  that  the  cellulitis  was  caused  by  the  treatment. 
The  case  occurred  at  a  time  in  my  practice  when  I  knew  less  about 
the  management  of  fungosities  of  the  uterus,  hence,  I  used  a  sponge 
tent  before  using  the  curette,  an  entirely  unnecessary  procedure.  I 
know  now  that  there  was  dilatation  enough,  but  I  followed  the 
rules  laid  down  in  the  books,  and  so  employed  the  tent  to  the 
disadvantage  of  the  patient.  I  am  satisfied  also  that  this  case  was 
due  to  sepsis,  for  at  that  time  less  was  known  about  antiseptic  sur- 
gery, and  I  have  no  reason  to  suppose  that  the  sponge  tent  and  the 
instruments  used  were  surgically  clean.  This,  I  believe,  from  the 
fact  that,  although  I  have  often  used  the  curette  since  then  and  oc- 
casionally sponge  tents,  I  have  never  caused  cellulitis.  Uncompli- 
cated cellulitis  rarely  proves  fatal ;  it  is  only  when  peritonitis  super- 
venes that  there  is  amch  danger  in  the  early  stages  of  the  disease. 
The  cases  that  end  fatally  do  so  usually  in  one  of  three  ways :  First, 
by  acute  septicaemia,  which  may  take  place  immediately  after  sup- 
puration occurs  ;  second,  by  chronic  septicemia  and  exudation  from 
prolonged  suppuration  in  badly-drained  cases ;  third,  and  very 
rarely,  when  the  abscess  opens  into  the  peritoneal  cavity,  and  at  once 
sets  up  a  septic  and  usually  fatal  peritonitis. 

Pelvic  Cellulitis  following  a  Haemorrhage  into  the  Cellular  Tissue. — 
A  young,  recently  married  lady,  while  very  much  fatigued  from  un- 
usual physical  exertion,  was  suddenly  seized  with  acute  pain  in  the 
pelvic  region.  When  called  to  see  her,  I  found  her  lying  in  bed 
suffering  from  severe  pain  and  some  rectal  tenesmus  :  the  pulse  was 
somewhat  accelerated,  but  the  temperature  was  normal ;  the  skin 
moist  and  cool.  There  was  no  constitutional  disturbance  beyond 
nervous  excitation  due  to  pain. 

On  examination,  I  found  a  tender  point  low  down  and  to  the 
right  of  the  uterus,  there  was  also  a  swelling  which  extended  to  tlie 
right  and  downward  a  little  way,  apparently  between  the  rectum  and 
vagina.  The  pain  was  relieved  by  opium,  and  on  the  following  day 
the  swelling  was  found  to  have  increased  and  become  denser,  and 
yet,  there  was  no  symptomatic  fever. 

Two  days  later  the  physical  signs  remained  the  same,  and  there 
was  also  a  marked  discoloration  or  ecchymosis  of  the  vagina,  especially 
in  the  upper  and  posterior  part  of  its  walls.  This  discoloration,  taken 
in  connection  with  the  history  of  the  case,  satisfied  me  that  the  case 
was  one  of  hiemorrhage  into  the  cellular  tissues  of  the  pelvis. 


568  DISEASES  OF  WOMEN. 

The  pain  gradually  l)ecaine  less  but  there  was  ttill  a  feeling  of 
fullness  and  ])re.ssure  in  the  pelvis  and  an  annoying  rectal  tenesmus, 
which  made  the  patient  feel  as  if  great  relief  would  he  obtained  if 
the  bowels  were  moved.  A  mild  laxative  was  given,  followed  by  an 
enema,  which  secured  a  free  evacuation  of  the  bowels,  but  in  place 
of  relieving,  this  rather  aggravated  her  sufferings.  On  the  sixth 
day  after  the  attack,  the  patient  felt  a  little  chilly,  and  soon  after- 
ward developed  fever  ;  there  was  also  a  slight  recurrence  of  the  acute 
pain  in  the  pelvis.  At  this  time  the  temperature  was  102^°  F.,  and 
the  pulse  about  110. 

On  the  day  following  this,  an  examination  was  made,  and  the 
mass  in  the  pelvis  appeared  to  be  softer  than  it  was  before ;  but  this 
I  think  was  due  to  cedema  of  the  vaginal  walls.  The  fever  con- 
tinued for  several  days  and  then  gradually  subsided,  and  the  tem- 
perature remained  about  100°. 

The  pain  and  general  pelvic  tenesmus  continued,  though  not  in 
a  marked  degree  ;  her  condition  remained  about  the  same  during  the 
following  week,  then  the  pain  became  more  severe,  the  tem])erature 
rose  a  degree  or  more,  and  she  was  more  restless  and  uncomfortable. 
Two  days  after  this  a  discharge  of  pus  from  the  vagina  occurred,  quite 
profuse  at  first,  and  contmued  in  a  modified  way  for  a  couple  of  days. 

The  discharge  contained  black  specks  which  were  found  to  be 
shreds  of  clotted  blood.  Forty-eight  hours  after  the  discharge  first 
appeared,  a  careful  examination  by  the  touch  was  made  in  the  hope 
of  discovering  the  opening  of  the  abscess,  but  without  success ;  a 
very  careful  speculum  examination  was  then  made,  and  by  the  aid 
of  the  probe  the  opening  was  found  to  the  right  and  a  little  below 
the  cervix  uteri.  The  openiog  appeared  to  be  just  above  the  maes, 
which  extended  down,  apparently,  between  the  vagina  and  the  rec- 
tum. A  uterine  dilator  of  small  size  was  passed  through  the  open- 
ing into  the  abscess  sac  and  slow  dilatation  made.  When  the  opening 
was  suiSciently  enlarged  to  admit  a  curette,  a  hirge  piece  of  blood- 
clot  was  removed  ;  several  strands  of  thick,  prepared  silk  were  intro- 
duced into  the  opening  to  keep  up  the  drainage,  and  during  the  next 
few  days  considerable  pus  was  discharged,  together  with  shreds  of 
old  blood-clots. 

As  the  opening  showed  no  disposition  to  close,  the  drainage  was 
abandoned,  and  from  this  time  onward  the  discharge  diminished  and 
the  swelling  and  thickening  of  the  tissues  also  slowly  disappeared. 
Finally,  the  discharge  stopped  altogether,  and  thickening  and  indura- 
tion of  the  tissues  gradually  disappeared,  and  complete  recovery  took 
place. 


PELVIC   CELLULITIS.  569 

Pelvic  Cellulitis  caused  by  Amputation  of  the  Cervix  Uteri. — This 
patient  came  iuto  the  hospital  about  eighteen  years  ago  with  a  very 
laiich  enlarged  and  eroded  cervix  uteri ;  in  fact,  the  cervix  seemed 
to  be  divided  into  two  lai-ge,  round  masses,  the  surfaces  of  which 
were  very  irregular  and  so  vascular  that  they  bled  ])rofusely  on 
touch.  This  was  before  Dr,  Emmet  had  told  us  about  laceration  of 
the  cervix  uteri  and  its  consequences,  and  I  supposed  that  the  case 
was  one  of  incipient  malignant  disease.  This  diagnosis  was  con- 
curred in  by  several  of  my  colleagues,  and  amputation  of  the  cer- 
vix was  deemed  the  best  mode  of  treatment,  and  the  oi)eration  was 
performed  after  the  method  commended  by  J.  Marion  Sims. 

In  removing  the  posterior  half  of  the  cervix,  I  am  satisfied  that 
I  went  beyond  the  walls  of  the  uterus  iuto  the  cellular  tissue  ;  sut- 
ures were  introduced  to  bring  the  flaps  together  and  to  hold  them 
there,  and  the  operation  appeared  to  be  quite  a  success.  At  the 
end  of  the  second  day  the  patient  developed  all  the  constitutional 
symptoms  of  local  inflammation  and  soon  afterward  the  physical 
signs  of  pelvic  cellulitis  were  manifested. 

The  subsequent  history  of  the  case  was  that  of  ordinary  pelvic 
cellulitis  which  ended  in  suppuration  and  discharge,  which  occurred 
at  a  point  corresponding  to  the  right  angle  of  the  junction  of  the 
flaps  made  in  the  amputation.  The  discharge  soon  ceased  and  all 
constitutional  and  local  disturbance  subsided,  and  the  patient  recov- 
ered from  the  acute  attack. 

She  subsequently  did  rather  badly,  there  was  considerable  con- 
traction of  the  scar  left  by  the  amputation,  and  there  was  evidently 
some  contraction  of  the  parts  involved  in  the  cellulitis  so  that  she 
suffered  a  good  deal  in  after  years  with  pelvic  pain  and  dysmenor- 
rhoea,  and  it  became  necessary  to  dilate  the  remaining  portion  of  the 
cervical  canal  in  order  to  give  relief.  This  case  is  mentioned  simply 
to  illustrate  cellulitis  as  it  occurs  after  operalions  about  the  ceiwix 
uteri,  and  it  no  doubt  was  septic  in  its  origin.  The  case  was  treated 
before  the  days  of  antiseptic  surgery,  and  I  have  no  doubt  that  I 
exposed  my  patient  to  all  the  septic  influences  possible  in  such  an 
operation.  Indeed,  the  management  of  the  whole  case  was  rather 
bad  as  it  appears  to  me  now,  and  I  am  inclined  to  believe  that  it  was 
not  at  all  malignant  to  begin  with,  and  that  amputation  of  the  cervix 
was  therefore  uncalled  for.  Such  a  case  now  would  be  considered 
as  a  laceration  of  the  cervix  with  areolar  hyperplasia,  and  would  be 
treated  in  the  usual  way. 

A  Case  of  Pelvic  Cellulitis ;  the  Abscess  opening  into  the  Eectum  and 
Long-continued  Suppuration  occurring  in  consequence. — This  patient 


570  DISEASES  OF  WOMEN. 

was  also  seen  in  hospital ;  she  gave  a  history  of  liaving  had  pelvic 
cellulitis  seven  months  before  admission.  About  live  weelcs  from 
the  time  that  she  was  taken  ill  she  had  discharges  of  pus  from  the 
rectum  which  were  followed  by  marked  relief.  After  this  she  con- 
tinued to  have  repeated  discharges  of  pus  in  the  same  way ;  for  a  few 
days  at  a  time  she  would  be  comparatively  comfortable,  though  never 
well ;  then  she  would  have  a  little  fever,  with  considerable  pain, 
and  then  a  discharge  of  pus,  which  would  give  relief  for  a  few  days. 
These  remittent  attacks  of  j)ain  and  fever  followed  by  a  discharge 
of  pus,  continued  at  varying  intervals  up  to  the  time  that  I  saw  her. 
On  digital  examination,  I  found  fixation  of  the  uterus,  with  evidence 
of  induration  in  both  broad  ligaments  and  around  the  cervix,  above 
the  vagina. 

She  was  anaemic,  emaciated,  and  had  a  somewhat  cachectic  ap- 
pearance. She  was  placed  under  ether,  and  a  most  careful  examina- 
tion of  the  rectum  made.  The  opening  from  the  rectum  into  the 
cellular  tissue  was  found  about  three  inches  up  the  rectal  wall,  by 
bending  the  probe  into  tlie  shape  of  a  hook.  I  was  able  to  pass  it 
from  above  downward  and  forward,  showing  that  the  opening  ran 
from  the  rectum  obliquely  downward  into  the  abscess  about  an  inch. 
A  counter-opening  was  made  in  the  most  dependent  part  of  the  sac 
through  the  vaginal  wall ;  the  opening  was  made  with  the  thermo- 
cautery. This  1  believe  to  be  the  best  method  of  making  counter- 
ojDenings  in  these  old  cases,  as  haemorrhage  can  be  avoided  and  the 
lymphatics  closed  by  the  cautery,  which  to  some  extent  guards  against 
septicaemia. 

The  opening  in  the  vagina  was  maintained  by  small  drainage- 
tubes  which  completely  drained  the  abscess.  The  patient  improved 
generally  and  locally,  and  after  a  time  the  drainage-tube  was  given 
up  ;  a  little  discharge  continued  from  the  opening  for  several  days, 
when  it  closed.  The  case  did  well,  and  was  soon  dismissed  from  the 
hospital,  although  there  still  remained  considerable  induration  and 
thickening  of  the  tissues  of  the  broad  ligaments.  Presuming  that 
her  recovery  would  be  eifected  in  time,  she  was  dismissed  from  the 
hospital ;  but  returned  in  about  three  months  with  a  rectal  abscess, 
which,  when  it  was  opened,  proved  to  bo  a  rectal  iistula.  Evidently, 
the  opening  in  the  vagina  had  closed  while  that  in  the  rectum  re- 
mained, thus  forming  an  internal  rectal  fistula.  This  was  treated 
in  the  usual  way  and  the  patient  iinally  recovered. 

Pelvic  Cellulitis ;  Abscess  discharges  through  the  Saphenous  Open- 
ing.— In  this  lady's  fourth  confinement  calcareous  degeneration  of 
the  placenta  was  found.     It  was  retained  for  a  long  time  in  spite  of 


PELVIC  CELLULITIS.  571 

all  the  ordinary  efforts  used  to  deliver  it ;  it  was  found  necessary  to 
detach  it  from  the  uterus,  a  very  difficult  task.  She  did  very  badly 
from  the  beginning,  soon  developing  a  metritis  and  celhilitis ;  she 
remained  in  a  very  precarious  condition  for  about  two  months  ;  the 
products  of  the  inflammation  formed  a  large  mass  on  the  left  side 
which  extended  up  to,  and  finally  became  adherent  to,  the  abdominal 
walls. 

Full  details  need  not  be  given,  suffice  it  to  say,  that  at  the  end  of 
twelve  weeks  an  abscess  opened  through  the  inguinal  canal.  Much 
relief  followed  the  opening  and  the  copious  discharge  of  pus,  but  it 
continued  to  discharge  for  weeks,  and  although  she  had  improved 
after  the  opening  of  the  abscess,  she  began  to  nm  down  from  this 
chronic  suppuration,  and  her  life  was  again  despaired  of.  A  probe 
was  passed  from  the  anterior  opening  and  downward  into  the  pelvis 
until  its  point  could  be  felt  on  the  left  side  of  the  cervix ;  there  was 
still,  however,  a  very  thick  wall  between  the  vagina  and  the  end  of 
the  probe.  After  faithfully  trying  the  effect  of  careful  washing  out 
and  drainage,  without  success,  a  counter-opening  was  made  through 
the  vagina  by  means  of  the  ther mo-cautery,  and  a  drainage-tube  carried 
through  the  opening  in  the  abdominal  walls  down  into  the  vagina. 
This  tube  was  injected  three  times  a  day,  and  as  the  patient  improved 
quite  fairly  the  tube  was  draven  down  toward  the  vagina,  leaving 
the  outer  opening  free.  No  discharge  occurring  at  the  abdominal 
opening  and  the  wound  showing  a  disposition  to  close,  the  tube  was 
gradually  withdrawn,  and  finally  removed  entirely.  The  discharge 
continued  for  sume  time  after  the  removal  of  the  tube,  but  finally 
ceased,  and  the  patient  recovered  and  has  remained  well  ever  since, 
a  period  of  eighteen  years. 

Pelvic  Cellmlitis  in  which  the  Discharge  was  delayed,  but  finally  re- 
lieved by  Aspiration. — The  history  of  this  case  has  nothing  peculiar 
in  it  except  that  it  progressed  as  cellulitis  usually  does,  until  the 
time  when  the  abscess  was  expected  to  discharge.  It  failed  to  do  so, 
and  the  patient's  general  nutrition  beginning  to  suffer,  it  was  deemed 
advisable  to  use  the  aspirator ;  this  was  done  and  the  abscess,  which 
was  in  the  right  broad  ligament,  was  emptied  of  about  eight  ounces 
of  pus.  This  gave  great  relief,  but  in  time  the  abscess  filled  again, 
and  again  it  was  aspirated,  but  this  time  before  removing  the  needle, 
the  sac  was  carefully  washed  out  with  carbolic  acid  and  water. 
Great  care  was  taken  not  to  inject  quite  as  much  as  the  quantity  of 
pus  removed,  for  fear  that  by  overdistending  the  abscess,  some  thin 
point  in  the  sac  might  rupture  and  cause  mischief. 

There  was  considerable  reaction  after  this  aspiration,  the  pulse 


572  DISEASES  OF  WOMEN. 

and  temperature  runniiio:  up,  but  soon  subsiding  again.  Nothing 
of  impui'tauee  occurred  in  the  history  of  the  case,  and  she  recovered 
in  due  time. 

A  Case  of  Cellulitis  terminating  in  Multiple  Abscesses,  cured  by 
enlarging  the  Opening  and  breaking  down  the  Walls  of  the  Small  Ab- 
scesses.— This  case  had  a  liistory  during  its  early  stages,  quite  in  ac- 
cordance with  the  ordinary  progress  of  the  disease,  but  after  suppu- 
ration and  discharge  the  patient  was  not  relieved,  and  the  suppura- 
tion continued.  The  opening  was  found  to  be  a  very  small  one, 
situated  behind  and  to  the  left  of  the  cervix  uteri.  After  trying 
every  possible  means  to  improve  her  general  condition  witliout 
effect,  the  opening  was  enlarged  by  dilatation,  the  patient  being  an- 
aesthetized ;  after  dilatation,  the  finger  was  passed  up  into  the  mass, 
and  the  walls  of  several  small  abscesses  broken  do\\Ti.  This  was 
rather  easily  accomplished  because  the  uterus  and  the  mass  of  in- 
flammatory products  were  low  down  in  the  pelvis  and  within  reach, 
and  while  the  finger  was  passed  through  the  opening,  the  other  hand 
was  placed  upon  the  abdomen  to  act  as  a  guide  and  to  guard  against 
breaking  through  into  the  peritoneal  cavity. 

After  this,  the  discharge  was  very  free,  and  a  number  of  shreds 
of  broken  tissue  were  evacuated.  Drainage  was  kept  up  and  the 
parts  washed  out  daily  until  the  mass  had  greatly  diminished  and 
the  discharge  had  almost  subsided.  The  drainage-tube  was  then 
removed  and  the  patient  slowly  recovered. 

A  Tedious  Case  of  Cellulitis  causing  Septicaemia  from  a  Very 
Small  Point  of  Suppuration ;  treated  by  Laparotomy  and  Drainage ; 
Recovery. — This  case  was  seen  in  consultation  with  my  friend 
Prof.  Jewett,  who  gave  me  the  following  notes  :  The  patient  was 
thirty  years  old,  and  was  confined  March  3,  1S85,  with  her  seventh 
child.  She  had  ante-partum  haemorrhage  and  inertia  of  the  uterus, 
wliich  rendered  it  necessary  to  deliver  with  forceps  at  the  superior 
strait.  The  nurse  was  incompetent,  drnnk,  or  stuj)id,  or  all  three, 
and  allowed  the  patient  and  her  bed  to  remain  filthy  for  two  days.  At 
the  end  of  the  third  day,  the  patient  developed  cellulitis  in  the  left 
broad  ligament ;  there  was  also  a  circumscribed  peritonitis  limited  to 
the  location  of  the  cellulitis.  At  the  beginning  of  the  disease,  the 
temperature  ran  up  to  103°  and  the  pulse  to  140 ;  this  elevation  was 
attained  on  the  Yth  of  March,  and  from  that  time  until  the  15th,  the 
temperature  I'anged  between  100°  and  102°,  and  the  pulse  between 
90  and  110,  There  was  a  marked  difference  between  the  morning 
and  evening  tempei'ature.  PVom  the  loth  until  the  20th,  the  con- 
stitutional disturbance  subsided,  the  local  inflammation  also  dimin- 


PELVIC   CELLULITIS.  5Y3 

ished,  and  there  was  every  reason  to  suppose  that  the  cellulitis 
would  end  in  resolution.  From  the  20th  to  the  28th  she  was  a])pa- 
rentl}'  convalescent,  and  was  able  to  walk  about,  but  on  the  29th  she 
had  a  relapse,  the  temperature  running  up  in  the  afternoon  to  104°. 
The  following  morning  it  was  down  to  97°,  and  from  this  onward 
to  the  18th  of  April  her  temperature  was  most  extraordinary  in  its 
variations.  On  the  4th  and  5th  it  was  105°  in  the  afternoon  and 
100°  in  the  morning;  from  the  0th  to  the  11th  it  ranged  between 
100°  in  the  morning  and  103°  and  104°  in  the  afternoon.  All  this 
also  in  spite  of  quinine  and  other  recognized  antipyretics.  From 
this  date  to  the  18th,  the  temperature  became  more  irregular,  occa- 
sionally dropping  down  to  98-|°,  and  suddenly  and  at  irregular  times 
running  up  to  103°  and  104°. 

It  was  thought  that  this  variation  of  temperature  was  due  to 
septicaemia,  and  yet  no  pus  accumulation  could  be  detected  in  the 
pelvis.  Prof.  Jewett  practiced  aspiration  with  negative  results,  but 
subsequently  made  a  number  of  appointments  for  further  explora- 
tions ;  but  the  patient  was  an  exceedingly  intractable  one,  and  her 
friends  had  no  control  of  her,  so  that  he  was  unable  to  carry  out  his 
wishes  in  this  regard. 

The  physical  signs  during  all  this  time  since  the  relapse  remained 
about  the  same.  The  patient  by  this  time  was  exceedingly  ansemic, 
the  skin  was  of  a  bronze  hue,  and  the  digestion  and  general  nutri- 
tion very  poor,  and. altogether  her  condition  was  critical. 

On  May  2d  she  submitted  to  an  ansesthetic,  and  Prof.  Jewett 
performed  laparotomy.  He  made  an  incision  through  the  abdominal 
walls  directly  over  the  tumor  in  the  broad  ligament,  and,  after  mak- 
ing a  small  puncture  in  the  tumor,  opened  up  the  cavity  with  the 
finger ;  no  pus  was  found,  and  not  more  than  a  teaspoonful  of  septic 
fluid  was  evacuated.  The  cavity  was  di-ained  and  irrigated  with  a 
bichloride  solution  for  about  four  weeks,  when  it  closed  completely. 

The  temperature  never  rose  above  101°  after  the  operation,  and, 
after  the  first  three  days,  it  became  normal,  and  remained  so  ever 
afterward.  She  rapidly  gained  in  her  general  health,  and  in  five 
weeks  had  completely  recovered. 

Pelvic  Cellulitis  ending  fatally  from  Septicaemia. — About  sixteen 
years  ago,  while  in  charge  of  the  lying-in  department  of  the  Long 
Island  College  Hospital,  one  of  my  cases  developed  a  metritis  and 
cellulitis  after  confinement.  The  case  progressed  in  the  usual  way, 
differing  in  no  respect  from  many  cases  of  the  kind,  excejit  that 
the  products  of  the  cellulitis  were  unusually  great.  The  metritis 
subsided,  and  the  cellulitis,  which  was  located  in  the  left  broad  liga- 


574:  DISEASES   OF   WOMEN. 

ment,  went  on  to  suppuration,  and,  while  I  was  looking  for  the  ab- 
scess to  discharge,  the  patient  began  to  show  eigns  of  septicivinia. 

There  was,  no  doubt,  a  large  accumulation  of  pus  in  the  broad 
ligament,  but,  as  we  were  unable  by  physical  signs  to  detennine  that, 
I  unwisely  abstained  from  exploring  the  abscess.  All  constitutional 
treatment  known  to  us  was  carefully  em})loyed,  but  the  ])atient  died. 
On  post-mortem  examination,  a  very  large  abscess  was  found  in  the 
left  broad  ligament,  and  nothing  more.  The  peritonaeum  covering 
the  abscess  was  congested,  and  there  was  much  subserous  (edema, 
but  not  the  slightest  evidence  of  any  peritonitis. 

This  case,  like  many  others,  illustrates  very  well  two  important 
points :  First,  that  cellulitis  occurs  without  the  slightest  pelvic  ])eri- 
tonitis  accompanying  it,  and  this  fact  tells  strongly  against  those 
who  make  no  distinction  between  the  two  affections ;  and,  second, 
if  this  case  had  come  under  my  observation  in  recent  years,  when  I 
appreciate  the  value  of  aspiration  and  abdominal  section  and  drain- 
age, as  taught  by  Lawson  Tait  (all  honor  to  him  for  this !),  the  case 
might  have  been  saved. 

Great  progress  has  been  made  in  the  management  of  cellulitis 
within  the  last  few  years  in  the  employment  of  aspiration,  counter- 
openings,  drainage,  and  abdominal  section  and  drainage,  as  the  above 
cases  have  illustrated. 

Acute  Cellulitis  treated  by  Aspiration  in  the  Stage  of  Serous  Infiltra- 
tion (by  Virgil  O.  Hardin,  of  Atlanta,  Georgia). — ''  The  patient  was 
twenty-four  years  of  age,  and  had  borne  a  child  three  months  before^ 
The  history  of  the  patient  showed  that  her  menses  had  always  been 
of  normal  character  up  to  her  pregnancy,  and  that  she  had  never 
suffered  from  any  symptoms  which  would  indicate  pelvic  disease  of 
any  kind.  Since  her  labor  she  had  had  tenderness  of  the  abdomen 
and  pain  in  walking  and  in  micturition.  Her  general  health,  how- 
ever, had  been  good.  On  the  day  before  I  saw  her  she  was  seized 
with  pain  in  the  back,  pelvis,  hips,  abdomen,  and  thighs.  This  pain 
was  acute  and  excessive.  Micturition  and  defecation  became  very 
painful,  especially  the  latter.  She  had  a  slight  chill,  followed  by 
high  fever,  thirst,  and  complete  loss  of  appetite.  When  seen  by 
me,  she  was  in  bed,  tossing  and  moaning  with  pain,  which  was  re- 
ferred principally  to  the  pelvic  region.  Pulse,  120,  temperature, 
101°,  skin  hot  and  dry,  face  flushed,  tongue  coated.  Vaginal  and 
rectal  examination  were  rendered  impossible  by  excessive  tenderness 
of  the  parts.  The  following  morning  she  was  fully  ansesthetized, 
and  a  complete  examination  effected.  The  vagina  was  hot  and  dry. 
The  cervix  was  lacerated  on  the  left  side.     The  womb  was  low  in 


PELVIC   CELLULITIS.  575 

tlie  pelvis,  and  was  pnslied  forward  against  the  bladder.  In  the 
posterior  fornix^  and  occupying  the  wliole  space  between  the  cervix 
and  the  rectum,  could  be  felt  a  rounded,  bulging  mass,  which  had  a 
boggy,  oedematous  feeling.  By  a  finger  in  the  rectum  this  mass 
could  be  outlined,  and  felt  to  extend  upward  about  an  inch.  No 
fluctuation  could  be  detected,  and,  when  pressed  by  the  finger,  the 
mass  could  not  be  displaced  upward.  Considering  the  condition  to 
be  that  of  pelvic  cellulitis  in  the  stage  of  serous  infiltration,  I  decided 
to  attempt  to  draw  off  the  serum  from  the  cellular  tissue,  hoping 
thereby  to  abort  the  disease  and  prevent  the  formation  of  solid  plastic 
exudation,  with  possibly  a  subsequent  abscess.  Accordingly,  an  as- 
l^irator-needle  was  thrust  into  the  tumor  from  the  vagina  at  three 
different  points  successively,  and  about  an  ounce  in  all  of  serum 
tinged  with  blood  was  withdrawn.  The  tumor  was  then  found  to 
be  so  softened  and  diminished  in  size  as  to  be  scarcely  perceptible 
to  the  touch.  A  quarter-grain  of  morphine  was  given  hypodermic- 
ally,  and  the  patient  ordered  to  remain  perfectly  quiet  in  bed,  and 
take  only  liquid  diet.  When  seen  twenty-four  hours  later,  she  had 
had  a  good  night's  sleep,  the  pain  in  the  pelvis  was  almost  entirely 
gone,  defecation  was  no  longer  painful,  appetite  had  returned,  the 
pulse  had  fallen  to  80,  the  temperature  to  99°,  and  the  patient  begged 
to  be  allowed  to  get  up.  The  mass  in  the  posterior  fornix  could  be 
felt  only  as  a  slight  thickening.  Two  days  later  the  patient  was  ap- 
parently in  her  usual  health." 

Pelvic  Cellulitis,  with  Certain  Complications,  which,  so  far  as  I 
know,  have  not  been  noticed  or  described  heretofore. — The  patient  was 
thirty-seven  years  of  age,  and  the  mother  of  six  children.  She  was 
confined  in  June,  and  was  fairly  well  for  five  days.  She  got  up  on 
the  fifth  day,  and  tried  to  attend  to  her  housework.  Four  days  later, 
while  about  the  house,  she  was  taken  with  severe  pain  in  the  jielvis, 
and  was  obliged  to  take  to  her  bed  again.  This  much  of  her  history 
was  obtained  from  the  patient. 

She  was  seen  for  the  first  time  by  Dr.  J.  H.  Raymond  about  six 
weeks  after  her  confinement,  and  he  learned  that  she  had  had  no 
regular  medical  care,  and  but  very  poor  nursing,  her  poverty  depriv- 
ing her  of  necessary  attention. 

From  the  history  and  physical  signs,  the  doctor  made  the  diag- 
nosis of  pelvic  cellulitis  of  the  left  broad  ligament.  The  tempera- 
ture at  that  time  was  nearly  normal  in  the  morning,  but  rose  to  101° 
or  102°  at  night.  There  was  marked  constitutional  distui'bance, 
such  as  generally  obtains  in  long-continued  suppuration  or  septi- 
caemia. 


576  DISEASES  OF   WOMEN. 

The  doctor  urged  her  to  go  to  tlie  hospital,  but  she  declined  until 
August,  about  ten  weeks  after  her  confinement.  During  the  inter- 
val from  the  time  tliat  she  was  first  seen  until  she  entered  the  hos- 
pital she  was  cojitined  to  her  bed  with  her  left  thigh  flexed  upon 
the  bodj,  and  the  leg  upon  the  thigh.  AVhen  she  was  admitted  to 
the  hospital  she  was  very  ansemic,  had  night-sweats,  and  had  the 
general  appearance  of  a  tubercular  patieut.  The  flexion  of  the  leg 
and  thigh  continued,  and  there  was  false  anchylosis  of  the  joints. 
The  tumor  in  the  pelvis  was  much  smaller  than  it  had  been,  but 
there  were  pain  and  tenderness  in  the  left  iliac  region,  extending 
up  to  the  lumbar  region.  The  temperature  ranged  from  100°  to 
103°,  being  very  irregular  in  its  rising  and  falling.  There  was  no 
point  in  the  pelvis  where  pus  could  be  detected,  and,  although  there 
was  some  swelling  in  the  left  side  of  the  abdomen,  no  signs  of  pus 
could  be  found  after  repeated  examinations.  She  was  able  to  take 
food  and  stimulants  fairly  well,  and  every  means  was  employed  to 
reduce  the  temperature  and  improve  her  strength,  but  without  any 
favorable  result. 

Hopes  were  entertained  that  the  location  of  the  suppuration 
would  be  found,  and  that  relief  might  be  obtained  by  aspiration  or 
other  means  of  evacuation.  In  spite  of  the  constitutional  treatment, 
she  gradually  declined,  the  anaemia  became  very  marked,  and  the 
temperature  increased,  frequently  being  101:°,  and  sometimes  a  frac- 
tion higher.  She  appeared  to  be  doomed  to  die  of  septicaemia,  and, 
as  a  last  resort,  it  was  decided  to  make  a  laparotomy,  in  the  hopes 
of  finding  the  source  of  the  septicaemia.  Immediately  before  giving 
the  ether  her  temperature  was  101|-°,  pulse,  11:0,  and  feeble. 

The  anchylosis  of  the  knee-  and  hip-joints  was  with  difficulty 
broken  up,  and  then  a  more  careful  exploration  of  the  left  iliac 
region  was  made.  There  were  swelling  and  hardening  of  the  wall 
of  the  abdomen  on  that  side,  but  not  to  any  great  extent.  An  as- 
pirating-needle  was  introduced  at  a  number  of  points  in  the  hope  of 
finding  pus,  but  without  avail.  The  abdomen  was  opened,  and  a 
most  careful  exploration  of  the  pelvis  was  made  by  the  touch.  The 
left  broad  ligament  was  considerably  thickened  and  much  less  elastic 
than  it  should  have  been,  showing  the  effect  of  the  inflammation, 
which  had  subsided.  Not  the  slightest  sign  of  any  point  of  sup- 
puration could  be  found,  but,  by  the  bimanual  touch,  with  the  fin- 
gers of  one  hand  in  the  aljdominal  cavity,  and  those  of  the  other  on 
the  outside,  I  detected  obscure  fluctuation,  indicating  that  an  abscess 
or  sinus  extended  along  that  side  of  the  abdomen.  The  location  of 
the  pus  having  been  clearly  marked,  the  wound  in  the  abdomen  was 


PELVIC   CELLULITIS.  577 

closed,  and  an  incision  was  made  in  the  side  down  to  the  pus.  It 
was  found  that  the  pus  cavity  was  very  small  at  its  lower  and  most 
superficial  end.  It  would  not  admit  the  little  finger.  This  ac- 
counted for  the  fact  that  it  was  not  found  with  the  exploring  needle. 
Passing  a  probe  from  the  opening  made  upward,  I  found  that  the 
sinus  was  wider  above,  and  extended  up  to  the  diaphragm.  The 
cavity  was  washed  out,  and  a  drainage-tube  introduced. 

Dr.  Palmer,  who  aided  in  the  ©iteration,  conducted  the  after- 
treatment,  and  the  following  facts  are  taken  from  his  record,  as  kept 
by  the  house-surgeon : 

The  patient  reacted  well  under  the  effect  of  morphine  and  atropia, 
given  hypodermically  at  the  end  of  the  operation,  and  again  in  three 
hours.  Whisky  with  hot  water  was  given  four  hours  after  the  opera- 
tion ;  she  retained  it  well,  and  from  that  time  onward  the  morphine 
and  whisky  were  given  to  meet  requirements.  Five  hours  after  the 
operation  the  temperature  was  99^°,  pulse,  128,  respiration,  28.  Two 
hours  later  the  pulse  went  up  to  100|^°.  The  night  was  passed  very 
comfortably,  but  she  required  morphine  and  whisky  in  large  doses, 
not  altogether  because  of  the  pain  or  exhaustion,  but  largely  from 
the  fact  that  she  was  used  to  both.  For  years  she  had  been  a  drinker, 
and,  during  the  long  illness  previous  to  the  operation,  she  had  taken 
morphine.  At  five  o'clock  on  the  following  morning  the  tempera- 
ture w^as  102°,  but  in  two  hours  it  came  down  to  99°. 

From  this  time  onward  her  progress  was  favorable,  at  times  the 
temperature  went  up  one  or  two  degrees,  but  came  down  when  the 
pus  sac  was  washed  out.  She  improved  in  strength  but  the  sup- 
puration high  up  in  the  cavity  continued,  but  in  a  much  less  degree. 

Her  lung-trouble  progressed  slowly,  but  she  seemed  doomed  to 
pulmonary  phthisis.  One  month  after  the  operation  there  was  still 
a  little  discharge  from  the  wound,  but  she  did  not  apparently  suffer 
from  that  to  any  extent,  but  her  cough  was  worse,  and  the  lungs  not 
improving.  At  this  time  she  returned  to  her  home.  The  final  re- 
sults I  have  not  yet  obtained. 

The  following  case  was  similar  to  the  above,  but  terminated 
fatally,  and  a  post-mortem  examination  revealed  the  exact  nature  of 
the  lesions. 

The  patient  was  thirty-seven  years  old,  and  had  been  confined  of 
her  fifth  child  four  months  previous  to  the  time  that  I  first  saw  her 
in  consultation  with  Dr.  R.  L.  Dickinson.  From  the  history  that 
we  could  gather,  she  had  fever  from  the  day  after  her  confinement, 
and  had  been  sick  ever  since.  She  was  emaciated,  and  her  skin  dry 
and  dusky ;  the  temperature  ranging  from  101°  to  102° ;  she  had 
38 


578  DISEASES   OF   WOMEN. 

but  little  appetite,  and  was  constipated.  She  rested  on  the  right  side 
with  the  legs  and  thighs  flexed,  and  complained  of  severe  pain  in 
the  right  groin  and  leg.  Owing  to  the  tixed  position  of  the  right 
leg  and  the  great  pain  which  she  sufl'ered  in  moving,  a  physical 
examination,  was  not  easily  made=  The  utems  was  apparently  nor- 
mal and  movable,  but  high  up,  at  or  above  the  brim  of  the  pelvis, 
on  the  right  there  were  evidences  of  inflammatory  products.  The 
diagnosis  of  abscess  in  the  false  pelvis  was  made,  causing  septicae- 
mia. She  was  taken  to  the  hospital,  and  explorations  were  made 
with  the  aspirator,  in  the  hope  of  finding  the  exact  location  of  the 
pus.  but  with  negative  icsulrs.  Laparotomy  was  perfonned  by 
Prof.  Charles  Jewett.  The  pelvic  organs  were  normal,  except  that 
there  were  evidences  of  a  former  cellulitis  in  the  upper  portion  of 
the  right  broad  ligament.  The  presence  of  pus  was  made  out  in  the 
right  iliac  and  luxabar  reg-ions  :  the  abdominal  wound  was  closed,  and 
an  opening  made  above  the  right  groin  into  the  abscess.  It  was 
foimd  that  the  abscess  cavity  extended  upward  along  the  spine  for 
twelve  inches.  The  subsequent  treatment  consisted  in  washing  out 
the  abscess  cavity,  and  suppoiting  the  patient  with  nourishment  and 
stimulants.  She  did  not  rally  well,  but  gradually  failed,  and  died 
the  thii'd  day  after  the  operation. 

The  autopsy  showed  that  the  abscess  cavity  extended  from  the 
right  broad  ligament  upward  Ijehind  the  kidney  and  to  the  right  of 
the  spinal  column  to  the  diaphragm.  The  psoas  muscle  was  in- 
volved in  the  abscess,  but  there  was  no  bone-disease,  and  it  was  the 
opinion  of  all  who  attended  the  autopsy  that  the  disease  began  as  a 
cellulitis  of  the  right  broad  ligament. 

A  case  similar  to  the  above  came  under  my  observation  twelve 
years  ago.  Upon  being  admitted,  the  patient  gave  a  history  of  cel- 
luhtis  following  confinement.  She  was  in  a  very  low  condition  from 
septicaemia.  I  found  signs  of  suppuration  in  the  left  ihac  region, 
and.  on  makino-  an  incision.,  I  found  a  large  abscess,  which  extended 
upward  to.  if  not  beyond,  the  diaphragm. 

The  patient  had  a  cough  with  purulent  expectoration,  but  no 
well-defined  signs  c-f  any  disease  of  the  lungs.  After  washing  out 
the  abscess  sac  with  cai'bolic  acid  and  water,  the  patient  declared 
that  she  could  taste  the  acid  ;  this  led  me  to  suspect  that  the  abscess 
had  opened  into  one  of  the  larger  bronchi :  water  colored  with  car- 
mine was  injected,  and  the  matter  expectorated  afterward  was  col- 
ored with  the  carmine. 

She  died  of  exhaustion,  and  at  the  autopsy  it  was  found  that  a  sinus 
extended  up  beliind  the  diaphragm  and  opened  into  a  Ijrouchial  rabe. 


CHAPTEK   XXXIL 


PELVIC   PEEITOJSnnS. 

The  peritonaeum  whicli  covers  the  pelvic  viscera  of  the  female  dif- 
fers in  no  respect  in  its  anatomical  construction  from  tlie  general  peri- 
toneum, and  its  function  is  the  same.  It  differs  only  in  the  organs 
which  it  covers,  and  in  the  fact  that  there  is  in  this  region  a  direct 
communication  and  union  between  the  mucous  and  serous  mem- 
branes at  the  opening  of  the  Fallopian  tubes. 


Fig.  208. — The  pelvic  peritonfeum  as  seen  on  locking  into  the  brim  (Hodge). 


580 


DISEASES   OF   WOMEN. 


From  tlie  fact  tliat  the  perit(jna^uin  is  a  continuous  membrane, 
one  would  naturally  suppose  that  an  inflanimatiou  beginning  at  one 


Fig.  209. — The  reflections  and  pouches  of  the  pelvic  peritonaeum  looking  into  the 

cul-de-sac  from  behind  (Hedge). 

point  would  incline  to  extend  to  tlie  whole  membrane,  so  that  gen- 
eral peritonitis  would  be  the  rule  in  the  patholoiry  of  inflammation 
of  this  membi'ane.  It  is  a  fact,  however,  that  the  pelvic  peritouseum 
becomes  the  seat  of  inflammation  very  often  and  without  any  general 
disposition  to  extend  to  the  abdominal  peritonaeum.  The  two  affec- 
tions then,  that  is,  pelvic  peritonitis  and  general  peritonitis,  while 
thej  are  the  same  in  their  pathology,  differ  so  in  their  clinical  his- 
tory and  causation,  as  to  render  them  two  separate  and  distinct 
affections. 

There  is  a  form  of  peritonitis  which  occurs  after  parturition,  in 
which  the  inflammation  begins  in  the  uterus  and  extends  to  the 
general  peritonaeum  and  is  known  as  metro-peritonitis,  but  tin's  also 
differs  entirely  from  peine  peritonitis,  which  occurs  far  more  fre- 
quently than  either  general  peritonitis  or  metro-peritonitis. 

The  pathology  of  pelvic  peritonitis  is  the  same  as  in  inflamma- 
tion of  serous  membranes  generally.  There  is  first,  subserous  con- 
gestion, followed  by  a  transudation  of  blood  =emm,  and  then  an 
exudation  of  plastic  material,  or  the  higher  organized  constituents  of 


PELVIC   PEKITONITIS.  581 

the  blood.  Ordinarily,  this  ends  the  formative  stage  of  the  inflam- 
matory process,  and  the  pi'oducts  of  the  inflammation  are  disposed  of 
flrst,  by  the  absorption  of  the  serous  transudation  and  the  organiza- 
tion of  the  exudate.  This  organization  simply  consists  in  the  devel- 
opment of  blood  circulation,  eitlier  in  or  beneath  the  exudate,  suffi- 
cient to  maintain  it  in  a  vitalized  condition  and  prevent  its  further 
degeneration  and  disintegration. 

The  peculiar  characteristic  of  this  exudate  is  to  form  adhesions 
to  adjoining  tissues  and  to  undergo  contraction  in  its  after-life,  so 
that  follovt'ing  an  attack  of  pelvic  peritonitis,  the  parts  in  the  grasp 
of  the  exudate  become  adherent,  and  are  often  drawn  out  of  their 
normal  position  by  its  contraction.  Occasionally,  but  rarely,  the  in- 
flammation of  this  serous  membrane  goes  on  to  suppuration.  When 
this  form  of  peritonitis  takes  place,  pus  accumulates  usually  in  the 
sac  of  Douglas ;  there  it  sometimes  is  walled  in  by  an  exudation  of 
lymph  which  unites  the  two  folds  of  the  peritonseum  which  form 
the  sac.  Occasionally,  too,  small  abscesses  may  be  formed  in  the 
exudate  which  is  thrown  out  around  the  ovaries  and  Fallopian  tubes. 

There  is  a  wide  range  in  the  degree  of  severity  in  cases  of  j)elvic 
peritonitis  ;  in  some,  a  cii'cumscribed  spot  of  inflammation  may  oc- 
cur which  gives  rise  to  a  little  discomfort  at  the  time,  and,  passing 
off",  leaves  no  suspicion  that  there  ever  had  been  an  inflammation 
there.  Tliese  cases  we  know  occur  from  the  fact  that  the  traces  of 
inflammation  are  found  post-mortem. 

From  these  circumscribed  and  exceedingly  mild  attacks,  we  find 
all  grades  of  severity,  up  to  the  most  marked,  where  the  whole  pelvic 
peritonaeum  is  involved  and  suppuration  occurs,  and  the  case  termi- 
nates fatally.  In  this  respect,  pelvic  peritonitis  strongly  resembles 
pleurisy,  the  milder  cases  representing  the  circumscribed,  dry  pleu- 
risy, and  the  more  severe  corresponding  to  that  of  pleuritic  em- 
pyema. 

There  is  also  another  form  of  pelvic  peritonitis,  in  which  there 
is  an  unusual  transudation  of  serum  which  accumulates  in  the  sac  of 
Douglas,  and  corresponds  to  the  ordinary  pleurisy  ^vith  effusion. 

Judging  from  the  number  of  cases  of  peritonitis  met  in  practice, 
and  also  from  observations  made  post-mortem,  this  is  one  of  the 
pelvic  diseases  which  occurs  perhaps  as  frequently  as  any ;  cer- 
tainly, it  is  much  more  common  than  pelvic  cellulitis  uncomplicated. 
It  no  doubt  occurs  quite  frequently  or  occasionally  in  the  progress  of 
other  pelvic  affections,  like  cancer  of  the  uterus,  pelvic  cellulitis,  sal- 
pingitis, etc.,  but  under  these  circumstances,  it  is  a  secondary  affec- 
tion, and  in  that  form  need  not  be  discussed  here. 


582  DISEASES  OF   WOMEN. 

In  less  severe  cases  the  exudation  gradually  disappears,  and  the 
niol)ility  and  fniietional  activity  of  the  jtelvic  organs  may  he  again 
restored  and  the  patient  may  be  considered  as  having  recovered. 
But  this  takes  a  long  time  before  it  is  accomplished.  When  pelvic 
l)eritonitis  terminates  fatally,  it  usually  does  so  because  the  inflam- 
mation has  gone  on  to  suppuration,  and  may  be  called  a  j)urulent 
peritonitis,  and  in  that  case  the  patient  may  die  in  a  few  days  from 


— Blas& 


Fig.  210. — Retroverted  uterus  bound  back  by  peritonitic  adhesions  ;  a,  6,  adhesions. 

(Winckel. ) 

the  time  of  the  attack,  either  from  shock  or  acute  septicaemia,  or 
both,  or  inflammation  may  extend  to  the  general  peritonaeum,  and  in 
that  way  sacrifice  the  patient. 

Causation.— \ii  regard  to  the  causes  of  pelvic  peritonitis,  we  find 
that  non-parous  women  are  most  liahle  to  it,  especially  those  who 
siLffer  from  imperfect  development  of  the  sexual  organs  and  de- 
rangement of  their  functions,  like  dysmenorrhoea,  for  example. 

The  immediate  causes  of  pelvic  peritonitis  are  of  three  kinds : 
First,  where  it  is  secondary,  and  e\Tdently  caused  by  some  affection 
or  inflammation  of  some  of  the  other  pelvic  viscera,  like  ovaritis, 
salpingitis,  and  endometritis.  Second,  traumatic  influences,  such  as 
injuries  of  any  kind,  imprudence  during  menstruation,  and  all  sur- 
gical operations  or  treatment.  In  those  who  have  suffered  long 
from  displacements  and  flexions  of  the  uterus  and  general  irritability 
and  congestion,  injuries  appear  to  be  sufficient  to  set  up  a  peritonitis, 
like  the  passing  of  a  uterine  sound,  or  the  application  of  caustics  to 
the  uterus.  Third,  specific  causes,  such  as  the  escape  of  septic  mate- 
rial from  the  Fallopian  tubes,  in  cases  of  endometritis  and  salpin- 
gitis, but  more  especially,  the  virus  of  gonorrhoea.  In  a  large  num- 
ber of  cases  the  cause  will  be  found  in  this  specific  virus ;  this  is 
the  reason  why  pelvic  peritonitis  is  such  a  common  affection  among 
prostitutes. 


PELVIC   PERITONITIS.  583 

The  duration,  termination,  and  after-consequences  of  pelvic  peri- 
tonitis, depend  largely  upon  the  extent  of  the  inllainmation  and  the 
cause  which  gives  rise  to  it.  In  some  cases  where  the  exudation  is 
limited  recovery  will  take  place  in  a  few  weeks,  and  but  little  after 
ill  effects  will  be  noticed,  except  occasional  ])ain  from  time  to  time 
in  the  region  of  the  exudate.  In  other  cases  where  the  whole  pel- 
vic peritoniBum  is  involved,  the  iimbriated  extremities  of  the  Fallo- 
pian tubes  become  involved  in  the  exudate,  and  are  virtually  de- 
stroyed. If  this  includes  both  sides,  the  function  of  the  ovaries 
and  tubes  is  arrested  because  of  the  damage  to  the  structure. 

Desencration  of  the  ovaries  often  follows  under  these  circum- 
stances;  sometimes  they  become  inflamed  and  succulent ;  at  other 
times  they  become  atrophied,  due,  no  doubt,  to  the  pressure  of  the 
contracting  exudate  and  the  interruption  of  the  circulation  in  them ; 
in  short,  in  some  of  these  cases,  the  adhesions  and  the  quantity  of 
exudation  so  destroy  the  anatomical  relations  that  on  post-mortem 
it  is  almost  impossible  to  recognize  the  tissues  or  organs.  A  mass 
of  tangled  adhesions  and  products  of  infl.ammation  covering  the 
uterus  and  broad  ligaments,  is  about  all  that  can  be  made  out. 

When  such  patients  live,  they  suffer  greatly  from  pelvic  pain 
and  dysmenorrhoea,  if  the  function  of  menstruation  is  not  arrested, 
as  it  sometimes  is,  by  the  destruction  of  the  ovaries. 

Symj>tomatology. — This  varies  according  to  the  severity  of  the 
attack  ;  in  average  cases  there  is  a  well-defined  symptomatic  fever, 
the  pulse  being  characteristic  of  inflammation  of  the  serous  mem- 
branes, being  small  and  wiry,  and  running  up  from  110  to  130  ;  the 
temperature  is  variable,  often  running  to  103°  F.  and  104°  F.,  and 
in  severe  cases  to  106°  F. 

At  flrst,  the  skin  is  usually  dry  and  hot ;  there  is  marked  de- 
rangement of  the  digestive  organs,  nausea  and  vomiting  often  occm'- 
riug  ;  sometimes  in  the  severer  cases  vomiting  of  that  greenish  ma- 
terial so  common  in  general  peritonitis,  occurs.  There  is  usually 
marked  tympanitic  distention,  and  the  patient  prefers  resting  quietly 
on  the  back  with  the  limbs  drawn  up,  a  position  which  seems  to  be 
the  easiest ;  there  is  usually  a  considerable  disturbance  of  the  nei*v- 
ous  system,  the  patient  being  anxious,  restless,  and  the  facial  ex- 
pression showing  anxiety  and  dread.  Sometimes  there  is  delirium, 
but  not  usually,  and  when  it  does  occur,  I  am  inclined  to  think  it 
shows  that  the  ovaries  are  affected ;  at  any  rate,  and  in  several  cases 
that  I  have  seen,  where  I  have  every  reason  to  believe  that  the  ova- 
ries were  also  inflamed,  there  was  great  mental  excitement,  and  tem- 
porary insanity  in  some. 


584:  DISEASES  OF   WOMEN. 

The  pain  in  the  pelvis  is  usually  acute,  much  more  so  than  in 
cellulitiri,  and  there  is  great  tenderness  to  the  touch  ;  the  pelvic  ves- 
sels are  generally  aifected,  and  there  is  marked  rectal  tenesmus,  and, 
if  the  jjeritonaeura  in  front  of  the  uterus  is  involved,  there  is  vesical 
tenesmus  also ;  in  fact,  this  vesical  irritation  is  often  an  exceedingly 
annoying  symptom. 

The  physical  signs  obtained  by  a  vaginal  examination  during  the 
first  stage  simply  reveal  tenderness  with  some  apparent  thickening 
of  the  roof  of  the  pelvis.  Tliis  may  be  limited  to  one  portion  of  the 
pelvis,  but  in  well-marked  cases  it  extends  throughout.  When  exu- 
dation has  taken  place,  complete  fixation  of  the  uterus  is  found, 
and  the  roof  of  the  pelvis,  as  felt  through  the  vagina,  presents  the 
extreme  hardness  which  is  characteristic  of  peritonitis,  and  has  been 
called  the  dealboard  hardness  by  some.  If  nmch  lymph  is  thrown 
out,  especially  if  it  is  associated  Avith  considerable  serum,  a  mass  will 
be  found  behind  the  uterus  occupying  the  sac  of  Douglas.  At  no 
time,  however,  do  the  products  of  this  form  of  inflammation  extend 
above  the  superior  strait,  unless  as  an  exceedingly  rare  exception  ; 
in  ease  that  the  disease  goes  on  to  the  formation  of  pus,  a  well-de- 
fined tumor  may  Ije  found  in  the  sac  of  Douglas,  and  if  this  pus  is 
discharged,  the  intense  hardness  at  that  point  may  disappear  in  part ; 
but  if  the  entire  exudation  is  lymph,  it  remains  hard  for  a  long 
time.  There  is  almost  always  a  displacement  of  the  uterus  as  well 
as  a  marked  fixation,  and  this  fixation  is  likely  to  remain  also ;  as 
contractions  occur  subsequently  the  position  of  the  uterus  may  be- 
come changed,  and  not  only  is  the  organ  thus  displaced,  but  it  is 
fixed  in  this  position. 

The  difiierence  between  the  physical  signs  of  pelvic  peritonitis 
and  other  diseases  of  the  pelvic  organs,  such  as  cellulitis  and  pelvic 
liajmatocele,  will  be  given  in  treating  of  the  signs  of  the  latter. 

Treatment. — The  objects  to  be  attained  in  the  treatment  of  pel- 
vic peritonitis,  are  first,  to  control  or  limit  the  inflammation  so  far 
as  possible,  and  to  relieve  the  pain  which  is  usually  very  great ;  by 
accomplishing  the  latter,  we  do  all  that  is  possiljle  to  effect  the 
former,  the  means  employed  to  relieve  pain,  fortunately,  having  the 
greatest  control  over  the  inflammation.  The  great  remedy  then  in 
the  earliest  stages  of  pelvic  peritonitis,  is  opium ;  Alonzo  Clark  was 
the  first  to  discover  the  value  of  this  agent  in  general  peritonitis, 
and  to  him  we  owe  most  of  our  knowledge  of  the  management  of 
this  affection,  and  it  is  equally  available  (that  is,  the  opium  treatment) 
in  pelvic  peritonitis. 

The  quantity  of  opium  to  be  given  should  be  measured  by  the 


PELVIC  PERITONITIS.  585 

effect  obtained ;  tlie  pain  should  be  relieved  and  kept  in  abeyance 
by  the  regular  administration  of  doses  sutticient  to  accomplish  this 
object ;  when  it  is  possible,  opium  or  morphine  should  be  given  by 
the  mouth,  because  in  this  way  the  patient  can  be  kept  more  uni- 
formly under  its  intiuence ;  it  often  happens,  however,  that  the 
stomach  is  too  irritable  to  retain  it  at  the  outset ;  the  morphine 
should  then  be  given  hypodermically  until  the  stomach  is  quiet.  In 
some  cases  where  there  is  marked  pelvic  tenesmus,  the  opium  may  be 
given  by  the  rectum ;  it  should  then  be  given  in  solution  or  enema, 
because  if  administered  in  suppositories  it  is  too  slightly  absorbed. 

Sometimes  in  giving  the  opium  in  this  way  it  will  aggravate  in- 
stead of  relieving  the  pelvic  tenesmus,  which  is  often  an  exceedingly 
annoying  symptom.  In  many  cases  the  patient  has  a  constant  de- 
sire to  urinate,  but  all  efforts  to  do  so  only  increase  greatly  the  suf- 
fering ;  this  induces  the  patient  to  resist  the  desire,  so  that  there  is 
a  vesical  tenesmus  with  retention  ;  under  these  circumstances  great 
relief  can  sometimes  be  given  by  the  careful  use  of  the  catheter. 
"Warm  applications  may  be  made  to  the  abdomen  in  the  form  of 
fomentations  ;  counter-irritation,  also,  is  often  useful,  which  may  be 
obtained  by  the  use  of  mustard-pastes,  turpentine  stupes,  etc. 

The  bowels  should  be  kept  constipated  by  the  free  use  of  opium, 
and  they  should  not  be  disturbed  until  the  acute  stage  has  passed 
off,  when  they  should  be  relieved  by  the  mildest  possible  means.  If 
the  patient  is  seen  at  the  very  onset  of  the  attack  and  the  rectum 
is  found  to  be  distended,  it  should  be  emptied  at  once  by  enema ; 
during  the  early  part  of  the  first  stage  if  the  stomach  is  as  it  usually 
is,  very  irritable,  very  little  wtII  be  accomplished  in  the  way  of  giv- 
ing nourishment ;  the  thirst  may  be  alleviated  by  giving  ice  or  very 
small  quantities  of  effervescing  waters.  If  there  is  great  prostra- 
tion a  little  champa,gne  and  Apolinaris  water  or  carbonic  water 
may  be  given  to  relieve  the  thirst  and  sustain  the  patient.  As  soon 
as  the  stomach  will  admit  of  it,  nourishing  food,  mostly  fluid,  should 
be  given ;  the  beef -extracts,  digested  milk,  and  gruel  will  usually  an- 
swer the  best  purpose.  At  the  end  of  the  acute  stage,  when  the 
pain  is  subsichng  or  relieved,  and  the  temperature  and  pulse  are 
down,  then  the  opium  can  be  greatly  reduced  in  quantity  or  given 
up  entirely  if  the  patient  sleeps  well ;  usually,  however,  small  doses 
will  be  required  at  night  to  secure  rest. 

The  next  object  in  the  treatment  is  to  favor  a  further  limitation 
of  the  plastic  exudation,  and  to  promote  the  absorption  of  the  in- 
flammatory products  ;  this  can  be  accomplished,  if  at  all,  by  the  use 
of  counter-irritation.     Small  blisters  applied  in  the  iliac  regions  and 


586  DISEASES   OF   WOMEJT. 

repeated,  often  give  the  patient  relief  from  disturbance,  and  appar- 
ently favor  the  absorption  of  the  inflammatory  ])roduets.  The  best 
method  of  employing  blisters  under  these  circumstances  is  to  a])ply 
two  blisters  on  each  side,  to  be  kept  there  until  it  is  thoroughly  vesi- 
cated, then  puncture  the  vesicle,  and  let  out  all  the  serum  and  allow 
the  cuticle  to  fall  down  upon  the  cutis,  and  then  apply  over  this  ab- 
sorbent cotton,  and  allow  it  to  remain  undisturbed  until  healing  is 
complete,  which  usually  takes  place  in  from  two  to  four  days ;  blis- 
ters may  again  be  applied  in  the  same  way.  During  this  time  the 
patient  should  be  sustained  by  nourishment  and  tonics,  quinine  be- 
ing one  of  the  most  reliable  agents.  AVhen  all  acute  symptoms 
have  subsided  and  there  is  no  evidence  of  any  serum  or  pus  accu- 
mulated in  the  pelvis,  the  further  disposition  of  the  inflammatory 
products  may  be  favored  by  the  use  of  iodine.  The  tincture  of 
iodine  may  l)e  applied  through  the  speculum  to  the  roof  of  the  pel- 
vis, that  is  around  the  cei-vix  uteri  and  upper  part  of  the  vagina, 
and  iodide  of  iron  may  be  given  internally.  Counter-imtants  from 
time  to  time  should  be  contiimed,  one  part  of  croton-oil  dissolved 
in  two  parts  of  sulphuric  ether  to  which  are  added  three  parts  of 
tincture  of  iodine,  makes  a  good  application  for  keeping  up  continu- 
ous irritation;  this  should  be  painted  over  the  lower  portion  of  the 
abdomen,  and  repeated  when  the  tine  eruption  which  it  produces 
bas  disappeared. 

These  remedies  should  be  changed  after  a  time  to  the  iodide  of 
potassium  or  the  bichloride  of  mercury  with  chloride  of  iron,  the 
latter  being  the  most  valuable  as  a  tonic  and  alterative.  While  there 
are  still  some  of  the  products  of  inflammation  remaining  in  the  pel- 
vis, or  at  least  for  a  long  time  after  the  subsidence  of  the  acute  in- 
flammatory symptoms,  the  greatest  possible  care  should  be  taken  to 
guard  the  patient  against  undue  labor  ;  standing,  walking,  or  riding 
may  produce  a  relapse,  and  hence,  the  patient  should  be  made  to 
carefully  feel  her  way  in  sitting  up  and  in  taking  exercise  ;  especially 
should  this  care  be  insisted  upon  at  the  menstrual  periods.  No 
rules  can  be  laid  down  with  reference  to  this  except  that  any  exer- 
cise which  excites  pain  should  be  avoided ;  short  stages  of  exercise, 
followed  l)y  rest  in  the  recumbent  position,  should  be  adhered  to,  a 
little  more  liberty  being  given  every  day,  in  case  it  does  not  pro- 
duce pain. 

All  exercise  of  the  sexual  functions  should  be  prohibited  until 
pain  and  tenderness  have  subsided.  In  case  there  is  an  accumula- 
tion of  serum  or  pus  in  the  sac  of  Douglas,  this  should  be  removed 
by  aspiration  ;  if  pus  is  found,  the  cavity  should   be  washed  out 


PELVIC  PEKITONITIS.  587 

with  a  weuk  solution  of  carbolic  acid  and  water,  or  of  bichloride  of 
mercury,  and  if  this  does  not  relieve  tiie  pain,  an  opening  may  be 
made  and  drainage  established,  but  this  is  usually  unnecessary. 

ILLUSTKATIVE    CASliJS. 

A  Typical  Case  of  Uncomplicated  Pelvic  Peritonitis. — A  lady 
twenty-five  years  of  age,  who  had  been  married  for  two  years,  and 
was  sterile,  began  to  menstruate  first  at  fifteen,  and  had  also  had 
dysmenorrhoea  slightly  for  the  first  years  of  her  adult  life,  but  it  was 
much  aggravated  after  her  marriage.  She  was  subject  to  attacks 
of  pelvic  pain,  though  not  severe,  after  much  exercise.  At  the  time 
of  the  attack  now  under  consideration,  she  was  menstruating,  and 
went  out  into  company,  and,  I  believe,  engaged  in  dancing,  and 
took  cold  on  her  way  home.  In  the  night  she  was  seized  with  vio- 
lent pain  in  the  pelvic  region,  with  nausea  and  vomiting.  She  was 
seen  early  in  the  morning,  and  her  temperature  was  found  to  be 
102°  F.,  and  her  pulse  120 ;  it  was  also  observed  that  she  was  a 
feeble-looking  person  of  a  tubercular  diathesis ;  there  was  much  ten- 
derness to  the  touch  in  the  lower  portion  of  the  abdomen,  and  also 
considerable  tympanitic  distention.  On  digital  examination,  there 
was  evidently  an  increase  in  ten)perature,  with  congestion  and 
marked  tenderness  in  the  region  of  both  broad  ligaments  and  behind 
the  uterus.  There  was  no  fixation  apparent  nor  hardening  of  the 
tissues,  but,  owing  to  the  increased  tenderness,  it  was  difiicult  to 
make  a  very  critical  examination.  The  rectum  was  distended  with 
fecal  matter.  A  hypodermic  injection,  consisting  of  ten  minims  of 
Magendie's  solution  of  morphia,  was  given,  and  warm  water  was 
injected  into  the  rectum ;  the  immediate  effect  of  the  enema  and 
evacuation  was  to  increase  the  pain,  and  in  two  hours  afterward  it 
was  necessary  to  give  five  more  minims  of  Magendie's  solution  hy- 
podermically ;  this  gave  considerable  relief,  but  it  did  not  produce 
sleep.  In  the  middle  of  the  day  she  was  found  to  be  still  restless, 
with  an  anxious  and  somewhat  pinched  expression,  and  expressed 
herself  as  fearful  of  some  dangerous  trouble.  Another  hypodermic 
injection  was  given,  because  she  still  had  nausea,  but  no  vomit- 
ing ;  late  in  the  evening  she  was  still  in  much  pain,  having  come 
partially  out  from  under  the  influence  of  the  opium ;  she  was  still 
nauseated,  and  her  temperature  was  103^]°  F.,  and  her  pulse  over 
120 ;  she  complained  of  some  headache,  felt  hot  and  feverish,  and 
yet  she  was  in  a  perspiration.  Fifteen  more  minims  of  Magendie's 
solution  was  given,  which  secured  for  her  several  hours'  sleep. 
Early  in  the  morning  she  was  found  wakeful  and  restless,  and  the 


588  DISEASES  OF   WOMEX. 

pain  bad  returned ;  her  stoinacli  still  i)eing  irritable,  anotber  ten 
minims  of  Magendie's  solution  of  morpbia  were  given ;  during  tlie 
nigbt,  while  awake,  small  pieces  of  ice  were  given,  which  were  grate- 
ful to  her,  but  she  was  still  thirsty,  and  begged  for  a  large  drink 
of  cold  water ;  she  was  given  half  a  wine-glass  of  cold  Vichy  every 
half-hour  when  she  desired  it ;  she  retained  some  of  this,  and  in  the 
forenoon  took  a  little  clear  coffee,  which  she  relished  and  retained. 
She  still  continued  to  suffer  from  nausea,  great  abdominal  tender- 
ness, and  considerable  pelvic  pain;  she  also  complained  of  a  very 
urgent  desire  to  urinate,  but  any  effort  to  do  so  gave  her  so  much 
pain  that  she  resisted  tlie  desire ;  the  nurse  was  directed  to  pass  the 
catheter,  which  she  did,  and  drew  off  less  than  half  a  pint  of  urine 
of  a  remarkably  dark  color.  At  night  she  again  had  fifteen  minims 
of  the  solution  of  morphia,  which  gave  her  a  few  hours'  sleep,  when 
she  again  awoke  with  pain  ;  ten  minims  was  then  given,  which  car- 
ried her  through  the  night  fairly  comfortable. 

On  the  third  day  after  the  attack,  upon  digital  examination,  the 
parts  of  the  portion  of  the  pelvis  within  reach  were  found  to  be  hard, 
and  the  utenis  fixed.  The  hardness  and  fixation  extended  entirely 
across  and  behind  the  broad  ligament  and  the  uterus ;  a  diagnosis  of 
pelvic  peritonitis  was  then  made  without  hesitation.  The  nausea  at 
this  time  was  less  marked,  so  that  she  retained  the  Yichy- water  and 
coffee  and  tea,  and  occasionally  a  little  beef-tea ;  but  these  were  ad- 
ministered in  small  doses,  care  being  taken  not  to  give  her  the  Yichy 
immediately  before  or  after  she  took  any  of  the  others. 

Every  little  change  in  the  temperature  was  observed  at  this  time. 
It  had  required  from  forty-five  to  fifty  minims  of  Magendie's  solu- 
tion to  keep  her  comfortable  during  the  twenty-four  hours  up  to  the 
end  of  the  third  day  ;  after  that  the  opium  was  given  by  the  mouth, 
twenty  minims  of  Squibl)'s  liquor  opii  comp.  were  given  every  three, 
four,  or  six  hours,  according  to  the  disturbance  or  pain  which  she 
had,  and  from  twenty-five  to  thirty  minims  at  bed-time.  This  was 
suflicient  to  keep  her  tolerably  comfortable,  and  to  secure  a  suflicient 
amount  of  sleep  in  the  night  and  an  occasional  nap  during  the  day. 
About  this  time  she  suffered  very  much  from  tymjxmitic  distention  ; 
occasionally  she  could  raise  gsts  from  the  stomach,  but  this  gave  her 
very  little  relief.  On  the  fifth  day  six  grains  of  quinine,  dissolved 
in  sulphuric  acid,  and  added  to  an  ounce  of  siru])  of  acacia  and  a 
little  warm  water,  was  given  by  enema ;  this  was  retained,  and  pro- 
duced partial  relief  from  tympanitic  distention. 

About  a  week  from  the  time  of  the  attack  the  pelvic  peritonneura 
was  evidently  covered  with  a  marked  exudation,  especially  that  por- 


PELVIC  PERITONITIS.  589 

tion  forming  the  sac  of  Douglas,  while  the  fixation  and  induration 
involved  the  entire  roof  of  the  pelvis ;  it  was  most  marked  behind 
the  uterus,  extending  down  to  a  point  on  a  level  of  the  surface  of 
the  cervix  uteri. 

On  about  the  eighth  day  a  marked  improvement  had  taken  place 
in  her  general  condition;  the  temperature  was  101-^°  F.,  and  the 
pulse  a  little  above  100  ;  her  tongue  was  still  thickly  coated,  but  was 
beginning  to  clean  off  on  the  end  and  sides ;  the  nausea  had  mostly 
subsided,  but  she  had  no  appetite ;  she  was  able,  however,  to  take 
a  fair  amount  of  fluid  nourishment — beef -extract,  digested  gruel,  and 
milk,  with  a  little  tea  and  coffee  from  time  to  time ;  she  still  had 
thirst,  and  took  considerable  water.  We  were  able  at  this  time  to 
reduce  the  quantity  of  liquor  opii  comp.  about  five  drops  every  three 
or  four  hours,  with  twenty-five  drops  at  bed-time.  At  this  time  we 
began  the  use  of  small  blisters,  and  continued  to  keep  the  lower  por- 
tion of  the  abdomen  in  a  state  of  irritation  for  the  next  ten  or  twelve 
days ;  she  was  also  given  a  pill  three  times  a  day,  composed  of  one 
grain  of  quinine,  one  tenth  of  a  grain  of  extract  of  belladonna,  one 
half  grain  of  comp.  extract  of  colocynth,  and  one  fourth  grain  of 
ipecac ;  this,  after  a  couple  of  days,  excited  some  peristaltic  action  of 
the  bowels,  and,  after  an  enema  of  soap-suds,  the  bowels  moved.  This 
relieved  the  tympanitis  considerably,  and,  although  she  felt  greatly 
distressed  immediately  after  the  movement  of  the  bowels,  she  was 
apparently  better  for  it. 

All  this  time  she  had  a  good  deal  of  irritation  of  the  rectum  and 
bladder,  and  a  constant  sense  of  fullness  and  distress  in  the  pelvis, 
with  pain  that  varied  very  much  in  severity.  From  this  onward 
she  suffered  very  little,  although  obliged  to  keep  quiet  in  bed  ;  she 
continued  to  take  a  fair  amount  of  nourishment  and  solid  food,  such 
as  rare  steak  and  a  chop,  which  with  toast  and  milk,  were  added  to 
her  bill  of  fare. 

The  quantity  of  opium  was  diminished  until  she  only  took  one 
dose  at  bed-time ;  the  pills  were  continued,  and  the  bowels  moved 
every  third  day  by  enema ;  the  temperature  had  now  come  down  to 
100°  F.,  and  the  pulse  to  95,  but  there  was  still  very  little  apparent 
difference  in  the  condition  of  the  pelvis.  This  line  of  treatment, 
including  the  counter-irritation,  was  continued  until  the  end  of  the 
third  week ;  at  that  time  she  was  permitted  to  sit  up  a  little  in  bed, 
and  was  able  to  turn  from  side  to  side  wdthout  much  discomfort. 
She  continued  in  this  way  for  three  days  longer,  when  the  pain 
l)egan  again,  and  the  pulse  and  tempera tm'e  ran  u]) ;  her  stomach 
became  again  disturbed,  although  there  was  no  vomiting,  and  the 


590  DISEASES   OF  "WOMEN. 

opiiiin  had  to  be  given  in  small  doses  more  frequently,  in  order  to 
relieve  lier — in  short,  there  was  every  ai)pearance  of  a  lighting  up 
of  the  acute  trouble,  but  the  temperature  did  not  go  beyond  101°  F., 
or  the  pulse  beyond  110,  and  she  was  exceedingly  irritable,  nervous, 
and  despondent  at  this  time ;  the  menstruation  then  came  on,  and 
after  a  day  her  pain  began  to  subside  a  little,  and  at  the  end  of  the 
third  day  her  condition  was  about  what  it  was  before  the  relapse 
took  place.  This  undoubtedly  was  simply  a  dysmenorrhoea  from  a 
lighting  up  of  the  inflammation. 

After  the  menstrual  flow  subsided,  she  improved  in  her  general 
condition  very  decidedly,  and,  at  the  end  of  tlie  flfth  week  from  the 
beginning  of  the  attack,  she  Nvas  able  to  sit  up  a  little  while  in  bed, 
and  to  be  occasionally  lifted  into  her  reclining-cliair.  Her  tempera- 
ture and  pulse  were  nearly  normal,  but  she  was  quite  weak,  and  still 
had  some  disturbance  in  the  region  of  the  pelvis ;  mildei-  forms  of 
counter-irritants  w^ere  employed,  occasionally  using  a  mild  mustard- 
paste,  and  sometimes  painting  with  the  tincture  of  iodine ;  she  was 
then  put  under  general  tonic  treatment,  including  quinine  and 
iron. 

The  bowels  were  kept  regular  by  the  pills  which  were  prescribed 
before.  At  this  time  there  was  still  marked  fixation  and  induration 
in  the  location  of  the  pelvic  peritonaeum,  and  from  this  onward  the 
treatment  consisted  in  good,  generous  nourishment,  wine,  and  tonics; 
the  iodide  of  iron  alternated  with  bichloride  of  mercury  and  chloride 
of  iron  was  continued  off  and  on  for  about  six  months ;  at  the  end 
of  that  time  her  health  was  about  as  good  as  it  was  before  she  was 
taken  ill,  although  she  suffered  more  from  her  dysmenorrhoea  than 
formerly,  and  was  obliged  to  keep  in  bed  during  the  menstrual 
period.  About  this  time  an  examination  was  made  when  the  indura- 
tion had  partly  disappeared,  but  not  wholly  ;  there  was  still  fixation 
of  the  uterus,  and  efforts  were  now  made  to  relieve  her  dysmenor- 
rhoea, wliich  was  evidently  due  to  an  anteflexion  of  the  body  of  the 
uterus,  by  enlarging  the  canal  by  gradual  dilatation  ;  the  first  at- 
tempt at  this,  however,  gave  rise  to  so  much  pain  and  suffering  that 
no  further  efforts  were  made  in  that  direction  at  that  time.  A  vag- 
inal  douche  of  hot  water  was  ordered,  but  that  did  not  give  her 
any  apparent  relief,  nor  did  it  appear  to  influence  the  disposition  of 
the  inflammatory  products.  Tincture  of  iodine  was  applied  around 
the  cervix  uteri  and  upper  portion  of  the  vagina  once  a  week  for  a 
month  or  two,  and  this  appeared  to  be  beneficial ;  at  least  she  im- 
proved while  this  was  being  employed,  but  I  presume  that  the  con- 
stitutional medication  had  most  to  do  with  her  progress — in  fact,  my 


PELVIC  PERITONITIS.  591 

experience  with  this  case  and  many  others  has  satisfied  me  that  local 
treatment  in  old  cases  of  pelvic  peritonitis  does  harm  ten  times  to 
once  that  it  does  good.  She  was  kept  upon  her  general  tonic  and 
alterative  course  of  treatment  for  six  months  after  suspending  all 
local  treatment,  and  then  it  was  found  that  there  was  a  marked  im- 
provement in  the  local  condition  ;  as  soon  as  tlie  slight  moljility  of 
the  uterus  was  established,  the  induration  and  fixation  much  more 
rapidly  diminished. 

The  patient  passed  from  under  my  observation,  but  returned 
again  in  two  years  to  be  treated  for  dysmenorrhcea,  and  I  then  had 
an  opportunity  of  examining  her  carefully,  and  found  considerable 
mobility  of  the  uterus,  and  also  of  the  broad  ligament ;  the  marked 
induration  had  wholly  disappeared — in  fact,  the  only  trace  of  her 
former  peritonitis  remaining  was  a  small  mass  in  the  most  dependent 
part  of  the  sac  of  Douglas ;  this  did  not  appear  to  give  her  any 
trouble ;  there  was  also  less  anteflexion  of  the  body  of  the  uterus. 
I  was  then  able  to  treat  her  for  her  dysmenorrhoea,  and  succeeded 
in  relieving  her  to  some  extent,  but  not  wholly.  Four  years  after 
I  heard  of  this  patient,  and  she  had  still  maintained  fair  health,  but 
suffered  slightly  at  her  menstrual  periods. 

A  Case  of  Circumscribed  Pelvic  Peritonitis  of  the  Mildest  Charac- 
ter.— A  young  lady  of  somewhat  delicate  organization,  who  had  suf- 
fered from  irregular  and  painful  menstruation,  was  seized  about  the 
time  of  one  of  her  periods  with  violent  pain  in  the  left  ovarian  re- 
gion ;  she  was  out  at  the  time  the  pain  came  on,  and  I  believe  was 
overfatigued ;  she  returned  home  and  went  to  bed,  and  I  saw  her 
several  hours  afterward ;  she  then  had  tenderness  on  deep  pressure 
in  the  left  iliac  region  and  also  had  pain  there  of  an  acute  character. 
Her  temperature  was  below  100°  F.,  but  her  pulse  was  over  100  ;  she 
was  somewhat  nervous  and  restless ;  I  gave  her  a  dose  of  bromide  of 
sodium  with  a  few  minims  of  liquor  opii  comp.,  and  ordered  it  to  be 
repeated  during  the  night  if  she  did  not  sleep. 

One  more  dose  was  necessary  to  give  her  a  comfortable  night, 
and  in  the  morning  when  I  saw  her  there  was  no  constitutional  dis- 
turbance except  a  loss  of  appetite  and  some  flatulence  ;  her  pulse 
w\as  a  little  rapid  and  there  was  still  pain  and  tenderness,  but  not 
marked,  in  the  left  side.  In  the  evening  of  that  day  her  menstrual 
flow  began  and  continued  normally  though  more  free  than  usual ;  this 
improved  her  condition  somewhat,  and  although  she  continued  in 
bed  for  al)Out  a  week  on  account  of  the  return  of  pain  upon  trying 
to  sit  up,  still  she  made  a  good  recovery,  and  was  around  as  usual 
the  week  following.     For  a  number  of  weeks  she  had  occasional  at- 


592  DISEASES  OF  WOMEN. 

tacks  of  pain  and  tenderness  on  that  side,  especially  at  her  men- 
strual periods. 

This  attack  passed  off,  and  she  was  in  fair  health  until  three 
years  afterward,  when  from  exposure  she  contracted  double  pneu- 
monia, of  which  she  died.  The  pliysician  who  attended  her  at  that 
time  obtained  a  post-mortem  examination,  and,  knowing  that  she  had 
been  a  patient  of  mine  at  former  times,  invited  me  to  be  present ; 
nothing  of  interest  being  found  in  the  thorax  I  suggested  the  pro- 
priety of  examining  the  pelvic  viscera  in  the  hope  of  determining 
the  pathological  conditions  which  gave  rise  to  her  irregular  and 
somewhat  painful  menstruation.  1  had  at  this  time  entirely  forgot- 
ten the  attack  above  described,  and  only  remembered  it  when  we 
found  the  ])roducts  of  the  pelvic  peritonitis  on  the  left  broad  liga- 
ment. The  fimbriated  extremities  of  the  Fallopian  tube  were 
matted  together  by  the  old  exudate,  and  the  peritonaeum  covering 
the  outer  portion  of  the  tube  and  extending  downward  showed  evi- 
dence of  an  old  inflammation ;  the  ovary,  however,  did  not  appear  to 
be  affected,  except  that  two  or  three  iimbrias  of  the  tube  were  ad- 
herent to  it.  This  case  illustrates  the  circumscril)ed  mild  form  of 
pelvic  peritonitis  which  occurs  quite  frequently  no  doubt,  but  is 
overlooked,  except  when  found  at  post-mortem. 

Septic  Peritonitis  Terminating  Fatally. — This  case  illustrates  the 
other  extreme  from  the  one  just  related.  A  strong,  healthy  servant- 
girl  had  leave  of  absence  on  Saturday,  and  staying  out  too  late, 
tried  to  save  time  by  crossing  a  13 eld  instead  of  taking  the  road 
home ;  and  upon  jumping  a  fence  near  the  house,  she  was  sud- 
denly seized  with  the  most  violent  pain  in  the  pelvis ;  she  reached 
home  with  great  difficulty,  and  was  helped  to  bed  by  her  fellow-serv- 
ants ;  nausea,  and  vomiting  came  on,  and  she  became  pale,  faint,  and 
covered  with  cold,  clammy  perspiration ;  the  physician  of  the  fam- 
ily, Dr.  "Woodruff,  was  sent  for  in  the  night,  and  by  the  judi- 
cious use  of  morphine  hypodermically  and  stimulants  administered 
by  the  rectum,  he  succeeded  in  bringing  her  out  of  her  state  of  par- 
tial collapse.  Her  temperature  then  rapidly  ran  up  to  105°  F.,  and 
her  pulse  to  130  ;  there  was  extreme  tenderness  of  the  abdomen 
and  distention ;  the  vomiting  continued  so  ]3ersistently  that  it  M'as 
impossible  to  administer  nourishment  or  medicine  by  the  mouth. 
The  physician  made  a  diagnosis  of  peritonitis  which  he  believed  to 
be  general,  and  I  saw  her  with  him  in  the  morning  and,  concurring 
in  his  diagnosis,  we  continued  the  use  of  opium,  but  her  pulse  had 
improved  and  the  stimulants  were  suspended.  The  temperature  and 
pulse  continued  very  high  and  her  general  appearance  was  more  like 


PELVIC   PERITONITIS.  593 

that  of  a  case  of  puerperal  peritonitis  tlian  any  otlier,  but  there  was 
still  some  hope  entertained  of  saving  her  until  Tuesday  afternoon 
when  she  began  to  vomit  that  greenish  material  so  often  seen  in  gen- 
eral peritonitis. 

Her  pulse  became  feeble  and  very  rapid ;  her  temperature  in 
the  vagina  ran  up  to  106°  F.,  and  she  appeared  like  one  passing  into 
a  state  of  collapse.  She  became  more  and  more  depressed,  and  died 
of  shock  on  Wednesday  morning.  The  case  being  somewhat  un- 
usual, a  grave  question  was  raised  as  to  the  causation ;  and  hence  a 
most  careful  post-mortem  examination  was  made. 

On  opening  the  abdomen  we  found  that  a  few  coils  of  the  small 
intestine  had  dipped  into  the  upper  part  of  the  pelvis,  and  were  ad- 
herent by  recent  soft  exudate  to  the  upper  part  of  the  uterus.  The 
sac  of  Douglas  was  found  nearly  full  of  pus,  and  the  whole  pelvic 
peritonaeum  was  covered  with  the  products  of  acute  inflammation. 
On  carefully  removing  the  pus  and  some  soft  lymph  from  the  sac  of 
Douglas  and  broad  ligaments,  a  recent  opening  was  found  in  one  of 
the  ovaries  which  led  to  a  cyst  not  larger  than  a  hazel-nut ;  in  this 
cyst  were  found  a  few  drops  of  brownish-looking  fluid  which  was 
preserved  for  microscopical  examination. 

The  general  peritonaeum,  except  that  covering  the  intestine 
which  rested  upon  the  uterus,  was  perfectly  normal.  Nothing  else 
abnormal  was  found  in  any  of  the  organs  of  the  body ;  the  heart 
was  rather  below  the  average  size,  and  so  were  the  blood-vessels ; 
beyond  this  all  was  normal. 

It  is  clearly  evident  that  this  girl  had  small  ovarian  cysts,  the 
contents  of  which  were  highly  septic,  and  when  the  rupture  occurred 
this  fluid  set  up  peritonitis,  which  being  highly  septic  in  character, 
developed  the  violent  attack  which  overwhelmed  the  patient's  nerv- 
ous system. 

A  Case  of  Pelvic  Peritonitis  caused  by  Gonorrhoea,  and  followed  by 
Pyosalpinx. — This  lady  was  twenty-six  years  of  age,  and  had  always 
enjoyed  very  good  health  until  she  was  married.  Two  years  after 
her  marriage  she  was  suddenly  taken  with  acute  vaginitis  and  ure- 
thritis ;  she  then  came  under  my  care,  and  I  then  made  a  diagnosis 
of  gonorrhoea  and  subsequently  procured  unmistakable  evidence  from 
her  husband  that  such  was  the  nature  of  the  attack. 

The  vaginitis  and  urethritis  yielded  promptly  to  treatment,  and 
she  was  dismissed  apparently  well,  but  returned  to  state  that  she  still 
suffered  from  uterine  leucorrhoea ;  I  then  found  a  well-marked  cerv- 
ical endometritis  with  some  remaining  vaginitis  of  the  upper  portion 
of  the  vagina.  AVhile  she  was  under  treatment  for  this  she  suddenly 
39 


594  DISEASES  OF  WO!0:N. 

developed  a  pelvic  peritonitis,  wliich  was  not  especially  severe  but  in 
which  there  was  considerable  exudation,  as  indicated  by  the  fixation 
and  induration  of  tlie  pelvic  organs.  Under  ordinary  treatment  she 
progressed  fairly  well,  but  the  case  was  unusually  tedious.  At  the 
end  of  the  year  1  considered  her  well,  but  she  still  had  some  pelvic 
pain  occasionally,  although  the  products  of  the  intianimation  had 
been  almost  entirely  disposed  of,  so  that  there  was  mobility  of  the 
pelvic  viscera  and  very  little  hardening  of  the  parts  except  in  the 
sac  of  Douglas  where  there  still  remained  some  of  the  old  exudate 
which  presented  a  somewhat  irregular,  nodulated  condition  to  the 
touch.  At  this  time  she  was  again  taken  ill  with  the  symjitoms  of 
another  attack  of  pelvic  peritonitis ;  the  pain  and  tenderness  on  this 
occasion,  however,  were  limited  to  the  left  side,  and  a  tumor  was 
soon  developed  which  was  elastic  to  the  touch ;  this  led  me  to  sus- 
pect that  this  was  a  case  of  salpingitis  instead  of  peritonitis,  and 
when  the  acute  symptoms  subsided  somewhat,  I  endeavored  to  con- 
firm my  suspicions  by  aspirating  the  tumor;  I  found  pus  and  was 
able  to  draw  off  about  an  ounce  and  a  half  of  it ;  the  sac  soon  filled 
up  again,  and  she  suffered  a  great  deal  of  pain  and  constitutional 
disturbance,  evidently  due  to  a  sliglit  septicaemia. 

As  the  case  was  one  of  long  duration,  she  became  discouraged 
with  my  treatment  at  this  time,  and  on  the  advice  of  friends,  went 
to  the  hospital.  I  learned  afterward,  that  while  in  the  hospital  she 
was  operated  upon,  the  distended  tube  being  removed  after  the 
manner  of  Lawson  Tait. 

A  Case  of  Pelvic  Peritonitis,  followed  by  Permanent  Displacement 
of  the  Uterus,  Dysmenorrhoea,  and  Cystitis. — This  was  a  married  lady, 
about  twenty-nine  years  of  age,  who  had  suffered  most  of  the  time 
from  dysmenorrhoea  and  sterility,  caused  by  anteflexion  of  the  body 
of  the  uterus  with  slight  retroversion.  During  the  treatment  for 
this  malformation  of  the  uterus  she  was  attacked  with  pelvic  peri- 
tonitis, the  exciting  cause  being  a  rather  forcible  effort  to  correct 
the  retroversion.  The  pelvic  peritonitis  ran  its  ordinary  course,  and 
terminated  in  recovery ;  but  afterward  the  uterus  was  found  in  a 
markedly  retroverted  condition,  and  bound  down  to  the  posterior 
wall  of  the  sac  of  Douglas ;  the  bladder  was  also  drawn  backward 
with  the  uterus,  and  held  in  that  position.  This  gave  rise  to  dys- 
menorrhoea quite  as  marked  as  that  from  which  she  suffered  before 
her  peritonitis.  The  malposition  of  the  bladder  caused  by  the  ad- 
hesions rendered  it  impossible  to  completely  empty  that  organ,  and 
the  partial  retention  of  the  urine  developed  a  very  troublesome 
cystitis. 


PELVIC   PERITONITIS.  595 

All  efforts  to  restore  the  uterus  and  bladder  to  their  normal  po- 
sitions were  without  avail.  The  dysiiienorrhoea  was  partly  relieved 
by  treating  the  cervical  endometritis,  which  she  also  had,  and  dilating 
the  internal  os  a  little.  The  cystitis  was  controlled  by  long-continued 
local  treatment,  but  she  still  suffered  from  some  pelvic  tenesmus, 
and,  in  fact,  remained  something  of  an  invalid  during  the  hve  or 
six  years  that  she  remained  under  my  observation. 

Pelvic  Peritonitis,  which  went  on  to  Suppuration,  the  Pus  accumu- 
lating in  the  Sac  of  Douglas ;  treated  by  Aspiration ;  and  Recovery. — 
This  patient  was  a  lady  who  had  married  and  had  borne  two  chil- 
dren, became  a  widow,  and  married  a  second  time,  and  who  had 
contracted  gonorrhoea,  which  led  to  a  severe  attack  of  peritonitis. 
There  was  nothing  peculiar  in  the  clinical  history  cf  the  case,  except 
that  it  was  very  severe,  but  she  progressed  fairly  well  up  to  the  time 
when  the  acute  symptoms  should  have  disappeared.  Her  tempera- 
ture and  pulse  continuing  high,  and  her  general  nutrition  showing- 
evidence  of  some  septic  influence,  it  was  presumed  that  pus  had  been 
developed  somewhere  in  the  pelvis,  and,  as  there  was  a  large  tumoi 
or  a  well-defined  mass  in  the  sac  of  Douglas,  the  aspirating-needle 
was  introduced  in  the  hope  of  finding  the  location  of  the  suppura- 
tion. 

Over  two  ounces  of  sero-purulent  fluid  were  drawn  off,  which 
improved  the  patient's  condition  almost  immediately ;  she  had  less 
pain  afterward,  her  pulse  and  temperature  improved,  and  her  gen- 
eral nutrition  also  ;  this  improvement,  however,  was  only  for  a  short 
time,  when  the  former  symptoms  returned,  and  aspiration  was  again 
practiced  with  the  result  of  finding  a  small  quantity  of  pus.  The 
sac  was  at  the  same  time  washed  out  with  a  solution  of  bichloride 
of  mercury,  and  from  this  onward  she  did  well,  although  she  did 
not  fully  regain  her  original  health ;  she  still  had  attacks  of  pelvic 
pain  at  times,  and  active  exercise  usually  brought  on  pelvic  tenes- 
mus. The  last  time  that  she  was  examined,  about  a  year  and  a  half 
from  the  time  of  the  pelvic  peritonitis,  there  was  still  considerable 
fixation  of  the  pelvic  organs  and  induration,  showing  that  the  prod- 
ucts of  the  bygone  inflammation  had  not  by  any  means  been  all  dis- 
posed of. 


CHAPTER  XXXIII. 


PELVIC    HEMATOCELE. 


Pelvic  hsematocele  is,  as  the  term  indicates,  an  accumulation  of 
blood  in  the  pelvis,  or,  more  strictly  speaking,  in  the  sac  of  Douglas, 
or  else  in  the  cellular  tissues  of  the  pelvis.  Of  course,  the  accumu- 
lation of  blood  is  merely  the  result  of  some  other  lesion,  and  conse- 


FiG.  211. — Subperitoneal  pelvic  htematocele.     U,  displaced  uterus  ;  B,  empty  bladder. 


PELVIC   HEMATOCELE. 


597 


quently  pelvic  hasmatocele  is  secondary  to  the  lesion  which  gives 
rise  to  it. 

There  are  two  forms  of  pelvic  hsematocele,  distinguished  accord- 
ing to  the  location  of  the  accumulation  of  blood  :  Subperitoneal 
pelvic  hgematocele,  or  that  in  which  the  haemorrhage  occurs  in  the 
cellular  tissues  (Fig.  211),  and  intra-peritoneal  hsematocele,  in  which 
the  blood  accumulation  is  in  the  pelvic  cavity — that  is,  in  the  sac  of 
Douglas  (Fig.  212). 

The  subperitoneal  variety  is  not  always  a  very  serious  affection, 
while  the  intra-peritoneal  variety  is  one  of  the  most  dangerous  dis- 


FiG.  212. — Inti'a-peritoneal  pelvic  hajmatoccle. 

eases  which  comes  under  the  observation  of  the  gynecologist ;  there- 
fore, the  former  will  be  dismissed  with  a  few  remarks  later,  while 
the  most  of  what  follows  will  refer  to  the  intra-peritoneal  variety 
wholly. 

The  sources  of  the  hsemorrhage  giving  rise  to  this  affection 
which  have  so  far  been  accurately  determined  are  from  rupture  of 
blood-vessels  of  the  ovaries  or  veins  of  the  broad  ligaments,  and 
from  rupture  of  an  aneurism  of  some  of  the  pelvic  arteries,  reflux 
of  blood  from  the  uterus  or  Fallopian  tubes,  and  general  transuda- 


598  DISEASES  OF  WOMEN. 

tion  from  tlie  smaller  blood-vessels  in  certain  conditions  of  tlie  blood, 
such  as  that  of  purpura,  for  example.  Rupture  of  the  sac  in  cases 
of  extra-uterine  pregnancy  has  also  been  mentioned  as  a  source  of 
hoBmorrhage,  giving  rise  to  pelvic  hagmatocele.  But,  as  extra-uterine 
])regnancy  is  a  matter  wholly  by  itself,  it  need  not  be  considered  in 
this  connection.  It  will  be  seen  from  this  that  the  conditions  which 
give  rise  to  haemorrhage  may  all  be  classed  under  two  heads — first, 
some  condition  of  the  bloodvessels  which  favors  their  giving  way, 
and,  second,  the  conditions  of  the  blood,  which  favor  haemorrhage, 
such  as  we  find  in  persons  of  the  haemorrhagic  diathesis. 

The  extent  of  the  accumulation  depends  to  some  extent  upon 
the  size  of  the  rujDtured  vessels.  If  the  haemorrhage  is  extensive, 
the  loss  of  blood  and  shock  may  cause  a  fatal  tei-mination  in  a  few 
hours.  This  shock  is  due  to  the  impression  made  upon  the  peri- 
tonseum  by  the  sudden  effusion  of  blood,  which  acts  as  a  foreign 
body.  If  this  does  not  occur,  and  the  haemorrhage  ceases,  then  pel- 
vic peritonitis,  sometimes  general  peritonitis,  supervenes,  and  the 
products  of  the  inflammation  are  thrown  around  the  blood-clot,  and 
in  this  way  it  becomes  walled  in.  If,  again,  the  patient  survives  the 
acute  peritonitis,  the  serous  portion  of  the  blood  is  slowly  disposed 
of  by  absorption,  and  in  time  the  solid  clot  softens  down  by  degrees, 
and  is  also  disposed  of  in  the  same  way ;  and,  again,  the  patient  may 
recover  with  the  pelvic  organs  damaged  l)y  the  inflammatory  pi'od- 
ucts,  which  remain  and  behave  very  much  as  in  simple  pelvic  peri- 
tonitis. Occasionally,  however,  it  happens  that,  in  place  of  the 
blood-clot  being  disposed  of  in  this  way,  it  breaks  down,  and  sujd- 
puration  of  the  products  of  the  peritonitis  occurs,  and  death  ensues 
from  septicaemia. 

This,  then,  gives  three  well-defined  stages  in  the  progress  of  pel- 
vic hsematocele :  Firet,  the  stage  of  hsemoi-rhage  ;  second,  the  stage 
of  pelvic  inflammation ;  and  third,  the  stage  in  which  the  clot  is 
disposed  of  by  absorption,  or  breaks  down,  and  gives  rise  to  sup- 
puration. 

The  extent  of  pelvic  peritonitis,  and  the  subsequent  disposal  of 
the  clot,  or  the  extent  of  suppurative  action  which  may  take  place, 
depends  to  some  extent  upon  the  quantity  of  the  blood  accumula- 
tion, and  also  upon  the  patient's  general  condition  at  the  time,  and 
the  character  of  the  blood. 

In  case  the  patient  is  not  in  \agorous  health  at  the  time  of  the 
haemorrhage,  and  if  the  haemorrhage  is  great,  the  shock  is  more 
likely  to  prove  fatal ;  or,  if  that  does  not  take  place,  then  the  extent 
and  character  of  this  inflammation,  and  the  tendency  to  decomposi- 


PELVIC   HiEMATOOELE.  599 

tion  and  snppurcation,  are  rendered  greater  in  case  the  blood  is  in 
any  way  abnormal. 

A  limited  quantity  of  normal  blood  in  the  sac  of  Douglas  does 
not  necessarily  give  rise  to  very  great  trouble,  but  we  can  readily 
suppose  that,  if  blood  is  abnormal,  as  in  the  case  of  scorbutus  or 
purpura,  then  it  is  more  likely  to  be  irritating,  and  hence  the  greater 
wdll  be  the  inflammation  and  tendency  to  suppuration.  The  accom- 
panying figures,  211  and  212,  illustrate  the  two  varieties  of  pelvic 
hsematocele,  classified  according  to  location. 

Causation. — The  causes  of  pelvic  hsematocele  are  necessarily 
predisposing  and  exciting.  There  are  three  predisposing  causes — 
certain  changes  in  the  blood-vessels  of  the  pelvis,  overdistention  of 
the  vessels  which  enfeebles  their  walls,  and  degeneration  of  the  walls 
of  the  blood-vessels,  which  renders  them  more  easily  ruptured  under 
extra  pressure.  Any  one  of  these  conditions  of  the  blood-vessels  may 
be  produced  by  continued  hypersemia  or,  more  especially,  engorge- 
ment. It  is  well  known  that  congestion  on  the  venous  side  of  the 
circulation  tends  to  degeneration  of  tissues  of  all  kinds,  and  the  walls 
of  the  blood-vessels  prove  no  exception.  Hence,  in  cases  of  long- 
continued  congestion  of  the  pelvic  organs  from  any  cause,  such  as 
obstruction  of  the  portal  circulation,  imperfect  involution  after  JDar- 
turition,  or  in  persons  whose  occupation  compels  their  continued 
standing  or  sitting,  the  strength  of  the  walls  becomes  impaired,  and 
they  are  liable  to  rupture.  On  the  other  hand,  in  certain  abnormal 
conditions  of  the  blood,  such  as  that  found  in  purpura  or  scorbutus, 
there  is  a  tendency  to  haemorrhage  from  the  small  vessels  under 
extra  pressure.  It  follows,  also,  that  the  predisposition  to  haemor- 
rhage will  be  most  marked  during  the  period  of  ovarian  activity,  and 
also  at  the  menstrual  ]3eriod. 

The  exciting  causes  of  pelvic  hsematocele  are,  in  a  word,  anything 
which  can  produce  overdistention  of  the  blood-vessels,  sudden  check- 
ing of  the  menstrual  flow,  maintaining  the  erect  position  for  any' 
great  length  of  time,  violent  exercise  and  overexertion,  and  the  like, 
injuries  or  falls,  and  when  the  haemorrhage  comes  from  the  Fallopian 
tubes  or  the  uterus,  it  is  caused  by  some  obstruction  of  the  cervical 
canal  or  the  Fallopian  tubes. 

Symptomatology. — In  the  majority  of  patients  who  have  this 
affection,  the  haemorrhage  is  often  preceded  by  symptoms  indica- 
tive of  some  pelvic  affection,  but  these  need  not  necessarily  be  suffi- 
ciently marked  to  call  the  attention  either  of  the  patient  or  the  phy- 
sician to  them  ;  so  it  may  be  said  that  the  symptoms  of  pelvic  hsem- 
atocele are  developed  suddenly.     The  symptoms,  of  course,  differ 


600  DISEASES   OF  WOMEN. 

as  the  disease  progresses,  each  stage  having  its  own  characteristic 
manifestations.  When  the  haemorrhage  occurs,  there  is  first,  severe 
pain  in  the  pelvis,  followed  soon  after  by  all  the  evidences  of  shock, 
such  as  faintness,  coldness  of  the  extremities,  pallor,  and  cold,  clammy 
perspiration,  a  feeling  of  nausea,  and  sometimes  vomiting.  If  the 
temperature  is  taken  at  this  time,  it  will  be  found  to  be  subnormal, 
and  the  pulse  irregular  and  rapid,  although  sometimes  it  is  slow  and 
feeble. 

In  a  short  time  to  these  symptoms  are  added  well-marked  pelvic 
tenesmus,  including  vesical  and  rectal  tenesmus,  and  tympanites. 
If  the  haemorrhage  stops  and  the  patient  recovers  from  the  shock, 
then  inflammatory  symptoms  are  developed. 

These  constitutional  and  local  symptoms  are  exactly  the  same  as 
tliose  observed  in  peritonitis,  because  they  are  due  to  the  peritoneal 
inflammation  which  usually  starts  up  about  forty-eight  hours  after 
reaction  from  the  haemorrhage.  If  the  patient  passes  through  the 
inflammatory  stage  and  the  blood  accumulation  is  disposed  of  by 
absorption,  the  symptoms  will  then  be  altered  to  a  modified  pelvic 
tenesmus  with  occasional  pain  of  a  mild  character  and  a  general 
malnutrition,  indicating  some  source  of  a  mild  form  of  septicaemia. 
On  the  other  hand,  if  suppuration  and  breaking  down  of  the  blood- 
clot  take  place,  the  constitutional  disturbances  as  indicated  by  high 
temperature,  rapid  pulse,  and  deranged  nutrition,  will  show  the  sep- 
ticaemia which  usually  takes  place  under  those  circumstances. 

Physical  Signs. — In  the  stage  of  haemorrhage  there  are  simply 
tenderness  and  distention  of  the  sac  of  Douglas,  indicated  by  a  mass 
which  fluctuates  on  pressure  ;  the  tumor  is  soft,  smooth,  and  uni- 
form. 

After  coagulation  has  taken  place  the  mass  becomes  solid,  but  is 
still  soft  and  yielding  to  the  touch  ;  the  uterus  is  displaced,  usually 
upward  and  forward,  so  that  the  cervix  will  be  found  just  behind 
or  above  the  symphysis.  The  rectal  touch  will  also  show  that  the 
tumor  presses  upon  the  bowel ;  abdominal  palpation  made  after  the 
tympanitic  distention  has  subsided,  will  often  show  the  mass  extend- 
ing up  to  the  superior  strait  and  sometimes  higher,  and  in  one  case 
that  I  saw,  the  blood-clot  extended  upward  half-way  to  the  umbiHcus. 

After  inflammation  takes  place  this  mass  becomes  surrounded 
above  with  the  products  of  the  inflammation  which  increase  the 
density  of  the  tumor  and  also  give  it  a  more  perfect  fixation.  After 
the  inflammation  has  subsided  and  the  serous  portion  of  the  blood 
has  all  been  absorbed  and  the  solid  clot  has  undergone  considerable 
contraction,  the  mass  that  was  originally  smooth  to  the  touch,  now 


PELVIC   HEMATOCELE.  601 

becomes  quite  irregular.  As  the  case  advances  still  further  and  the 
blood-clot  breaks  down  and  suppuration  occurs,  the  mass  may  be- 
come softer  and  give  the  impression  of  obscure  fluctuation  to  the 
touch.  The  great  difficulty  which  the  diagnostician  encounters  is  to 
distinguish  between  pelvic  cellulitis,  pelvic  peritonitis,  and  hsemato- 
cele.  It  is  also  stated  that  pelvic  haematocele  may  be  confounded 
with  retroversion  of  the  uterus,  extra-uterine  pregnancy,  flbroid 
tumors,  and  inflammation  of  a  small  ovarian  cyst  which  is  lodged  in 
the  sac  of  Douglas,  and  hydro-  or  pyo-salpinx.  There  is  very  little 
likelihood  of  confounding  so  grave  an  affection  as  pelvic  hsemato- 
cele,  the  clinical  history  of  which  is  so  marked,  with  any  of  the 
above-named  conditions,  except  it  might  be  an  acute  inflammation 
of  an  ovarian  cyst,  located  in  the  sac  of  Douglas,  or  a  Fallopian  tube, 
very  greatly  distended  with  serum,  pus,  or  blood.  In  either  of  these 
conditions — except  the  latter — if  a  diagnosis  could  not  be  made,  and 
it  was  important  at  once  to  do  so,  the  use  of  the  hypodermic  syringe 
used  as  aspirator,  would  settle  the  question  definitely. 

Treatment. — During  the  stage  of  haemorrhage  this  consists  in 
using  means  to  arrest  the  hsemorrhage,  relieve  the  pain,  and  sustain 
the  patient  against  the  shock  and  loss  of  blood.  To  control  the  haem- 
orrhage the  patient  should  be  placed  on  the  back  with  the  head 
and  shoulders  slightly  elevated,  in  order  that  the  blood  as  it  accu- 
mulates in  the  pelvis  may,  by  its  own  weight,  make  pressure  upon 
the  rupture  in  the  vessel.  Cold  applications  to  the  abdomen  have 
been  recommended,  but  usually  are  not  well  borne.  Pressure  made 
by  applying  a  compress  and  bandage  is  more  likely  to  do  good  ;  to 
relieve  the  pain  and  sustain  the  patient,  morphine  given  hypoder- 
mically  is  the  most  reliable  and  valuable  of  all  remedies ;  under  the 
circumstances  the  opium  acts  as  a  stimulant  as  well  as  a  relief  to 
pain.  In  case  the  shock  is  great  and  liable  to  prove  fatal,  stimulants 
should  be  used  hypodermically  or  by  the  rectum  ;  but  in  many  cases 
the  rectum  will  not  retain  them  owing  to  the  irritability  caused  by 
the  hsematocele. 

It  has  been  proposed  by  Dr.  M.  A.  Fallen  to  open  the  abdomen, 
remove  the  blood,  and  stop  the  hgemorrhage  by  ligating  the  rupt- 
ured vessels.  This,  theoretically,  appears  to  be  good  surgery,  but 
unfortunately  it  can  never  have  any  very  wide  practical  application  ; 
the  fact  is  it  should  never  be  undertaken  in  cases  where  the  shock 
and  depression  are  great,  because  the  patient  would  most  certainly 
die  under  the  operation,  and  in  the  less  severe  cases  of  haemorrhage 
which  are  not  attended  by  any  great  shock,  it  can  usually  be  arrested 
by  milder  means.     I  can  conceive  of  no  condition  where  laparotomy 


602  DISEASES  OF  WOMEN. 

would  be  justified,  except  in  cases  where  the  haemorrhage  is  slow 
but  persistent.  If  one  is  satisfied  that  a  haemorrhage  is  going  on 
in  the  pelvic  cavity,  which  persists  in  spite  of  all  ordinary  efforts 
to  check  it,  and  the  patient  does  not  suffer  from  shock,  then  lapa- 
rotomy might  be  undertaken  ;  such  cases,  however,  are  extremely 
rare,  and  it  is  difiicult  to  diagnosticate  the  conditions  above  men- 
tioned ;  hence,  I  think  that  it  will  be  seldom,  if  ever,  that  this  prac- 
tice will  be  followed.  However,  abdominal  surgery  has  attained 
such  a  degree  of  perfection  in  the  hands  of  some,  at  the  present  day, 
that  it  is  well  to  keep  this  mode  of  treatment  in  mind  as  a  possible 
means  to  be  employed. 

When  the  inflammatory  stage  begins  the  treatment  should  be  the 
same  as  that  already  advised  in  cases  of  pelvic  peritonitis,  and  if  the 
case  progresses  favorably  the  treatment  should  be  continued  on  the 
same  principle.  If,  however,  suppuration  takes  place,  and  the  pa- 
tient is  placed  in  danger  of  septicaemia,  the  question  arises  how  to 
relieve  that  condition.  There  are  two  methods,  either  or  both  of 
which  may  be  employed  if  the  location  of  the  pus  can  be  reached 
through  the  vagina  ;  aspiration  may  be  practiced,  and  if  that  gives 
relief  it  may  be  repeated  if  need  be ;  if,  however,  this  fails,  the 
needle  may  be  again  introduced  until  the  pus  is  reached,  and  being 
left  there  as  a  guide,  a  larger  opening  may  be  made,  and  drainage 
established  ;  or  laparotomy  and  drainage  may  be  practiced. 

Years  ago,  Kecamier  proposed  to  evacuate  the  blood-clot  as  soon 
as  the  patient  had  sufficiently  rallied  from  the  shock  of  haemor- 
rhage ;  by  so  doing  he  hoped  to  lessen  or  avert  entirely  the  inflam- 
matory stage  and  the  long  tedious  and  sometimes  dangerous  process 
of  disposing  of  the  clot.  Nelaton  took  up  this  practice,  but  soon 
found  that  it  was  a  dangerous  proceeding,  inflammation  and  septi- 
caemia of  a  dangerous  character  being  very  liable  to  follow.  It  is 
possible  that  to-day,  with  the  great  improvements  in  sm-gery,  this 
practice  might  give  better  results  than  in  years  past ;  one  thing  I 
am  sure  of,  and  that  is  if  the  blood-clot  is  not  disposed  of  in  a  quiet 
and  favorable  way  but  sets  up  a  suppuration  after  the  inflammatory 
stage  is  past,  T  should  be  in  favor  of  evacuating  it.  This  I  have 
tried  successfully  in  one  case,  a  rather  desperate  one  it  was  too,  and 
with  perfect  success.  I  would  not,  however,  advise  operating  except 
under  the  conditions  named,  because,  if  the  evacuation  of  the  clot  is 
undertaken  before  it  is  walled  in  by  inflammatory  products,  there  is 
ver}^  great  danger  of  starting  up  another  hemorrhage  which  might 
not  be  controllable,  and  again  there  is  more  danger  of  exciting  peri- 
tonitis which  might  become  general,  and  end  fatally. 


PELVIC  HEMATOCELE.  603 


ILLUSTRATIVE    CASES. 


A  Case  of  Pelvic  Hsematocele  uncomplicated. — A  lady  of  some- 
what phlegmatic  temperament  who  was  also  ehlorotic,  had  suffered 
all  her  life  from  dysmenorrhoea  in  a  marked  degree,  and  also  scanty 
menstruation  as  a  rule,  although  at  times  this  was  more  free.  She 
had  been  twice  married,  the  last  time  for  eight  years,  but  had  never 
been  pregnant.  In  taking  her  previous  history  at  the  time  I  lirst 
saw  her,  I  found  that  she  had  symptoms  of  some  former  pelvic  dis- 
ease, probably  general  congestion  as  indicated  by  her  dysmenorrhoea, 
leucorrhoea,  and  pelvic  tenesmus  which  was  aggravated  on  walking. 

She  had  lived  a  somewhat  indolent  life  taking  very  little  phys- 
ical exercise.  When  I  saw  her  first  I  learned  that  on  the  last  day  of 
her  menstrual  flow  she  had  been  riding  and  walking  more  than 
usual,  as  she  had  some  visitors  whom  she  was  entertaining  by  tak- 
ing them  about  the  city. 

While  getting  out  of  her  carriage  she  slipped  and  fell  on  the 
sidewalk  ;  she  was  taken  with  pain  in  the  left  side  of  her  pelvis,  and 
had  to  be  helped  into  the  house,  and  immediately  went  to  bed ;  her 
pain  increased  in  severity,  and  she  became  very  faint  and  nauseated  ; 
I  saw  her  about  two  hours  after  this  slight  accident,  and  found  her 
suffering  from  partial  shock ;  her  pulse  was  exceedingly  feeble  and 
rather  rapid ;  her  temperature  was  97^°  F.,  and  her  skin  was  cold 
and  clammy ;  she  was  sighing  frequently,  and  had  an  expression  of 
extreme  anxiety  and  distress  ;  she  had  vomited  frequently  and  was 
exceedingly  nauseated ;  she  complained  in  a  low  whispering  voice  of 
a  violent  pain  in  the  vaginal  pelvis.  There  was  considerable  tympa- 
nitic distention  of  the  abdomen  with  marked  tenderness  in  the  epi- 
gastric region.  On  digital  examination  I  found  considerable  tender- 
ness, but  not  as  much  as  might  have  been  expected. 

There  were  signs  of  fluid  in  the  sac  of  Douglas,  but  this  was  eas- 
ily displaced  by  the  touch ;  a  diagnosis  of  pelvic  hsemorrhage  was 
made,  and  hypodermic  injections  of  morphine  were  given  sufficient 
to  relieve  her  pain  ;  a  little  brandy-and-water  was  also  administered 
at  first,  but  this  she  almost  immediately  rejected  ;  an  abdominal  band- 
age and  compress  were  applied  without  giving  any  distress  for  two 
or  three  hours,  but  at  that  time  she  complained  of  its  tightness,  and 
it  was  necessary  to  remove  it ;  bottles  of  hot  water  were  applied  to 
the  feet  and  limbs  and  also  to  the  arms,  which  were  kept  under  the 
bed-clothing.  All  this  gave  her  relief  from  pain  to  some  extent 
and  the  shock  did  not  apparently  increase,  and  yet  she  showed  very 
little  disposition  to  rally.     About  three  hours  afterward  some  brandy 


604  DISEASES  OF   WOMEN. 

and  beef-extract  were  given  by  enema,  and  repeated  at  intervals  of 
two  or  tliree  hours  for  some  time  ;  the  hypodermic  injections  of 
morphine  were  also  repeated  as  often  as  every  three  hours  durini: 
the  tii*st  twelve  hours.  During  this  time  she  was  given  a  grain  and 
a  half  of  morphia  altogether.  She  then  began  slowly  to  recover 
from  her  shock,  the  haemorrhage  evidently  having  stopped  ;  lier 
pulse  became  more  rapid  and  a  Httle  fuller ;  she  breathed  more  nat- 
urally, and  her  skin  became  warm ;  she  also  had  less  of  that  extreme 
faintness  and  depression  ;  still  she  remained  nauseated  althougli  she 
was  able  to  retain  very  small  quantities  of  brandy  and  Seltzer-water 
and  beef-extract ;  the  pain  however  was  not  any  less  except  when 
controlled  by  the  morphine.  In  addition  to  this  she  complained  of 
marked  pelvic  tenesmus,  especially  of  the  bladder  and  rectum.  She 
described  this  feeling  as  one  of  great  fullness,  weight,  and  pressure 
in  the  pelvis,  which  she  fancied  would  be  relieved  by  free  evacua- 
tion of  the  bowels.  She  remained  in  this  condition  with  very  little 
change ;  taking  opium  freely  and  very  little  nourishment  for  about 
forty-eight  hours ;  at  that  time  the  physical  signs  showed  that  the 
sac  of  Douglas  was  tilled  with  blood  which  was  now  beginning  to 
coagulate  as  shown  by  the  less  pelvic  fluctuation  on  touch.  Her 
temperature  now  rather  rapidly  increased,  running  up  to  103°  F., 
her  pulse  became  more  rapid  and  fuller ;  the  pain  also  increased, 
and  nausea  and  vomiting  again  returned.  She  was  now  very  tym- 
panitic and  had  acute  tenderness  on  touch  in  the  lower  part  of  the 
abdomen ;  in  short,  she  had  all  the  symptoms  of  acute  pelvic  peri- 
tonitis with  unusual  marked  constitutional  disturbance,  owing  no 
doubt  to  the  general  depressed  condition  due  to  pelvic  haemorrhage. 

On  the  fourth  day  there  were  well-defined  evidences  that  the 
products  of  the  pelvic  inflammation  were  being  developed  ;  there 
was  much  greater  hardening  of  the  parts,  and  the  mass  in  the  sac  of 
Douglas  was  solid  or  more  solid  as  indicated  by  the  touch.  From 
this  onward  the  physical  signs  were  those  of  a  pelvic  peritonitis 
with  an  unusual  accumulation  in  the  sac  of  Douglas. 

The  progress  of  the  case  from  this  time  was  that  of  a  severe  pel- 
vic peritonitis^  and  the  treatment  was  the  same  as  has  already  been 
described,  hence  nothing  further  need  be  said  on  that  subject.  At 
about  the  end  of  the  third  week  the  physical  signs  were  the  same, 
except  that  on  examination  a  mass  appeared  behind  the  uterus  which 
was  somewhat  irregular,  small  depressions  and  elevations  being  de- 
tected here  and  there  ;  the  temperature  and  pulse  had  both  come 
down,  and  yet  remained  above  100  ;  the  patient  was  now  able  to  take 
a  fair  amount  of  nourishment,  and  her  bowels  were  moved,  but  with 


PELVIC   HiEMATOCELE.  G05 

the  greatest  possible  difficulty  ;  laxatives  and  repeated  enemata  were 
given  each  time  that  an  evacuation  was  obtained,  and  she  also  suf- 
fered great  distress  when  the  bowels  moved.  About  this  time  she  be- 
gan to  show  decided  malnutrition ;  she  had  lost  considerable  flesh, 
was  pale  and  rather  slightly  bronzed  looking,  and  her  skin  was  dry 
and  ill  conditioned,  giving  the  impression  that  the  absorption  of  the 
serous  portion  of  the  blood  was  probably  causing  a  mild  form  of 
septicfiemia.  From  this  time  onward  her  progress  was  exceedingly 
slow  but  entirely  satisfactory  under  tonics,  nourishing  diet,  and  mild 
counter-irritation  over  the  hypogastric  region;  she  gradually  re- 
gained her  strength.  The  pain  and  discomfort  in  the  pelvic  region 
had  become  very  trifling  except  when  she  tried  to  take  exercise. 
There  was  no  change  in  the  physical  signs  except  that  the  mass  in 
the  sac  of  Douglas  had  greatly  diminished  in  size,  and  the  uterus 
which  had  been  pushed  upward  and  forward  close  to  the  pubes,  had 
returned  in  part  toward  its  normal  position.  The  hardening  of  the 
pelvic  roof  and  the  fixation  of  the  jDelvic  organs  remained  about  the 
same. 

It  is  needless  to  follow  the  progress  of  this  case  from  day  to  day ; 
suffice  it  to  say  that  she  made  a  very  slow  recovery,  that  at  each 
menstrual  period  she  suffered  great  disturbance,  and  that  for  a  long 
time  was  unable  to  walk  or  ride  without  suffering  pain.  Tonics, 
alteratives,  and  nourishing  diet  were  given  which  improved  her  gen- 
eral condition. 

Ten  months  after  the  attack  there  were  still  signs  of  an  excessive 
exudation  in  the  pelvis,  and  also  the  remains  of  a  blood-clot  in  the 
sac  of  Douglas ;  still,  from  this  time  onward  she  was  able  to  enjoy 
life  in  her  own  somewhat  indolent  way,  but  could  not  walk  or  ride 
without  suffering  more  than  in  former  yeai'S.  A  year  and  a  half 
subsequently  I  had  the  opportunity  of  examining  the  pelvis,  and 
found  that  there  was  still  considerable  fixation  of  the  pelvic  organs, 
and  also  some  hard,  irregular,  small  masses  in  the  sac  of  Douglas, 
but  she  did  not  appear  to  suffer  very  much  from  these,  and  her  gen- 
eral health  was  fairly  good. 

Pelvic  Haematocele ;  Evacuation  of  a  Clot ;  Recovery. — A  French- 
woman, occupied  as  polisher  in  a  watch-case  factory,  where  her  duties 
required  her  to  occupy  a  standing  position  all  day  long,  was  suddenly 
taken  ill  while  at  work ;  violent  pain,  followed  by  faintness,  came 
on  while  she  was  at  work.  She  was  carried  from  the  factory  to  her 
home  near  by,  and  one  of  my  assistants  was  called  to  see  her.  He 
attended  to  her  immediate  wants,  and  saw  her  again  afterward,  when 
he  made  a  digital  examination,  and  found  a  fluctuating  mass  in  the 


606  DISEASES   OF   WOMEN. 

sac  of  Douglas.  On  the  second  day  he  gave  me  a  detailed  history 
of  the  case,  and  we  came  to  the  conclusion  that  she  must  have  had 
a  pelvic  liaemorrhage ;  the  inflammatory  action  soon  set  in  after  she 
rallied  from  the  shock  which  occurred,  and  was  very  severe  at  the 
onset  of  the  disease,  and  she  was  again  in  a  most  dangerous  condi- 
tion. Being  poor,  her  surroundings  were  very  unsatisfactory,  and, 
by  advice  of  the  doctor,  she  was  removed  to  the  hospital;  she  was 
admitted  about  ten  days  after  the  time  that  she  was  taken  ill.  At 
that  time  the  pelvis  appeared  to  contain  one  solid  mass,  so  that  noth- 
ing could  be  distinguished  except  a  somewhat  shortened  vagina  and 
the  cervix  uteri,  which  was  curled  up  and  hrmly  iixed  behind  the 
pubes.  Her  bowels  were  very  much  distended,  and  she  suffered  ex- 
tremely from  pain  and  tenesmus ;  her  general  condition  was  very 
wretched,  indeed,  and,  as  it  was  impossible  to  move  the  bowels,  the 
question  arose,  What  could  be  done  to  relieve  the  extreme  pressure 
in  the  pelvis  which  threatened  to  destroy  the  organs  and  tissues,  and 
prove  fatal  ?  I  had  the  extreme  good  fortune  to  secure  the  counsel 
of  the  late  Prof.  William  Warren  G-reene,  and  we  decided  to  evacu- 
ate the  blood-clot  in  the  hope  of  thereby  saving  the  life  of  the  pa- 
tient ;  accordingly,  an  incision  was  made  through  the  posterior  vag- 
inal wall  into  the  most  dependent  part  of  the  tumor,  which  extended 
well  down  into  the  middle  line  of  the  pelvis ;  a  large  blood-clot 
was  found,  which  was  broken  up  and  evacuated,  and  the  cavity  cau- 
tiously washed  out.  ISTo  haemorrhage  of  any  amount  followed,  and 
she  was  very  much  reheved.  I  succeeded  then  in  moving  the  bowels, 
which,  while  it  distressed  her  at  the  time,  subsequently  gave  her 
relief.  The  improvement  lasted  but  a  little  while,  however,  for  she 
soon  develojDed  a  violent  septicfemia,  and  it  now  appeared  as  if  she 
certainly  must  die ;  she  became  delirious,  her  pulse  was  extremely 
rapid  and  feeble,  her  temperature  was  105^°  F.,  and  she  was  bathed 
in  clammy  perspiration ;  her  breath  also  had  that  peculiar  sweetish 
odor  characteristic  of  septicaemia  or  pyaemia. 

There  was  a  free  discharge  of  pus  at  this  time  from  the  wound. 

Every  effort  was  made  to  sustain  her  by  stimulants  and  quinine, 
given  by  the  mouth  and  rectum  also,  and  the  sac  was  washed  out 
carefully  and  frequently  with  boracic  acid  and  water.  For  two  days 
it  seemed  as  if  she  might  die  at  any  time. 

A  free  and  profuse  diarrhoea  came  on,  and  lasted  for  several 
hours,  and,  at  a  consultation  held  by  the  surgical  staff  of  the  hospital, 
all  agreed  that  she  had  very  little  chance  of  recovery.  The  treat- 
ment was  thoroughly  carried  out,  and  soon  the  blood-])oisoning  began 
to  diminish,  the  sac  became  smaller,  the  discharge  less  free,  and, 


PELVIC   HiEMATOOELE.  607 

finally,  the  wound  closed,  and  she  recovered  from  all  but  the  prod- 
ucts of  the  inflammation,  and  these  remained  slightly  diminished  up 
to  the  time  that  she  was  discharged  from  the  hospital,  three  months 
from  the  time  that  she  was  admitted.  When  she  left  the  hospital 
her  general  health  was  fairly  good,  but  there  was  still  fixation  of  the 
pelvic  organs,  and  marked  induration  extending  across  the  pelvis 
behind  the  broad  ligament  and  uterus.  I  found  out  afterward  that 
she  took  care  of  her  household  after  her  return  from  the  hospital, 
and  about  six  months  afterward  returned  to  her  occupation  in  the 
factory,  where  she  remained  at  work  when  last  heard  of,  two  years 
from  the  time  she  was  first  taken  sick. 

A  Case  of  Subperitoneal  Hsematocele ;  Recovery. — A  lady,  whose 
age  does  not  appear  in  my  notes,  was  married,  and  had  three  chil- 
dren, and  was  under  my  care  for  endometritis,  associated  witli  a  good 
deal  of  general  congestion  of  the  pelvic  organs.  She  was  progressing 
fairly  well  until  one  day,  when  she  went  to  New  York  shopping ; 
she  walked  and  stood  considerably,  and  on  her  way  home  in  the 
afternoon,  after  crossing  the  ferry,  decided  to  walk  to  her  house,  a 
distance  of  about  three  quarters  of  a  mile  ;  she  did  this  because  she 
was  somewhat  proud  of  her  improvement  under  treatment.  When 
about  haK  through  her  short  journey,  she  was  seized  with  pain  in  the 
left  side  of  the  pelvis,  which  became  so  severe  that  she  was  obliged 
to  sit  down  on  the  door-steps  of  a  house  near  by,  and,  after  resting 
for  a  short  time,  she  managed  to  get  home,  went  to  bed,  and  applied 
a  mustard-paste  over  the  painful  side ;  the  next  day  or  two  she  re- 
mained in  bed,  the  pain  gradually  diminishing,  though  it  did  not 
wholly  disappear.  Four  days  afterward  she  rode  to  my  office,  and, 
on  digital  examination,  I  found  a  round,  rather  flat  tumor  in  the  left 
broad  ligament,  low  down  ;  it  was  somewhat  solid  to  the  touch,  and 
tender.  Being  very  desirous  of  knowing  what  this  peculiar  and  sud- 
denly developed  tumor  could  be,  I  introduced  a  small  aspirating- 
needle,  and  drew  off  a  few  drops  of  blood-serum  and  a  few  very 
minute  shreds  of  blood-clot,  but  failed  to  find  anything  more,  al- 
though I  made  a  strong  effort  to  do  so.  I  then  withdrew  the  needle, 
and  found  that  it  contained  a  long  shred  of  blood-clot ;  this  satisfied 
me  that  she  had  had  a  haemorrhage  into  the  cellular  tissue  of  the 
broad  ligament.  I  watched  her  with  care  and  anxiety,  but  there  was 
no  inflammatory  action  established  at  that  point,  and  the  tumor 
slowly  and  completely  disappeared. 

Subperitoneal  Pelvic  Hsematocele  discharging  into  the  Pertioneal 
Cavity,  and  ending  fatally. — The  following  case  is  taken  from  the 
work  of  Thomas  on  "  Diseases  of  Women  "  :  "  In  a  case  which  I  saw 


608  DISEASES   OF  W0ME5T. 

with  Dr.  Emmet,  we  were  unable  to  make  a  diagnosis  of  a  tumor 
wliicli  lay  obliquely  anterior  to  the  uterus.  In  twenty -four  hours 
the  patient  fell  into  a  state  of  collapse,  and,  as  we  saw  her  thus,  the 
nature  of  the  tumor,  which  we  were  doubtful  about  on  the  previous 
day,  became  evident.  Upon  a  post-mortem  examination,  an  ante- 
uterine  ha?matocele  as  large  as  a  goose's  egg  was  found  under  the 
peritonaeum,  through  which  it  had  broken,  discharged  a  portion  of 
its  contents  into  the  peritonaeum,  and  caused  collapse  and  death. 
This  is  the  only  ante-uterine,  but  not  the  only  subperitoneal,  haema- 
tocele  with  which  I  have  met." 

For  an  illustration  of  subperitoneal  pelvic  hsematocele  giving 
rise  to  cellulitis  and  suppuration,  the  reader  is  referred  to  a  case 
given  under  the  head  of  "  Pelvic  CelluUtis." 


DISEASES  OF  THE  UEIl^AEY  OEGAKS. 


CHAPTER   XXXIY. 

ANATOMY  AND  DEVELOPMENT  OF  THE  BLADDER  AND  UEETHEA. 

This  portion  of  the  present  work  is  undertaken  witli  the  full 
assurance  that  the  medical  profession  is  in  need  of  a  systematic  and 
practical  treatise  on  the  diseases  which  affect  the  urinary  organs  of 
the  female  sex,  and  that  such  a  treatise  should  be  included  in  every 
work  on  gynecology  which  lays  claim  to  being  complete.  Those 
engaged  in  active  practice  often  encounter  cases  of  cystic  disease 
among  their  female  patients,  many  of  which  are  exceedingly  trouble- 
some if  not  altogether  impossible  to  manage.  There  is,  moreover, 
but  little  in  English  literature,  at  least,  to  aid  them  when  thus  per- 
plexed with  the  difficulties  of  diagnosis  and  treatment. 

In  considering  this  important  subject  after  the  plan  which  I  have 
adopted,  much  will  be  purposely  omitted,  which,  though  interesting, 
is  not  absolutely  necessary  to  a  clear  understanding  of  its  essential 
principles.  The  conflicting  views  of  various  authors  regarding  un- 
settled questions  will,  when  possible,  be  entirely  disregarded  in  order 
to  make  room  for  the  more  practical  points  which  the  physician  is 
expected  to  carry  with  him  in  his  daily  practice.  In  short,  it  will 
be  my  purpose  to  supply,  so  far  as  I  may  be  able,  the  deficiency  in 
this  branch  of  medical  literature,  the  existence  of  which  a  busy  life 
in  private  practice  and  in  teaching  medical  students  and  post-gradu- 
ates has  demonstrated. 

To  proceed  systematically,  I  will  first  take  up  the  form  and  struct- 
ure of  the  bladder  and  urethra,  and  the  relations  which  they  bear  to 
other  organs  and  tissues  in  the  female,  and  then  pass  on  to  the  con- 
sideration of  their  development. 

Anatomy  of  the  Bladder. — The  bladder  is  a  musculo-membranous 
sac,  situated  in  the  anterior  part  of  the  true  pelvis.  Its  form  varies 
with  the  age  of  the  individual  and  the  degree  to  which  it  is  dis- 

40 


610 


DISEASES   OF   WOMEN. 


tended.  In  childhood,  the  vertical  diameter  is  the  longest ;  in  mid- 
dle life,  the  transverse ;  in  old  age,  from  the  sagging  of  the  infe- 
rior fundus  and  gradual  atrophy  of  the  pelvic  organs,  the  vertical 
again  becomes  the  longest  diameter.  When  empty,  its  walls  are 
closely  coajDtated,  and  it  lies  behind  the  pubes.  Between  the  pubes 
and  the  bladder  is  a  space  containing  loose  fat.  When  moderately 
filled,  it  rises  slightly  above  the  pubes,  and  assumes  a  somewhat  ovoid 
shape,  which  is  much  more  marked  during  distention.  In  the  fe- 
male the  bladder  has  a  shorter  antero-posterior  and  a  greater  lateral 
diameter  than  in  the  male. 

The  bladder  in  the  female  is,  for  accuracy  and  convenience  of 
description,  divided  into  corpus  (body),  fun- 
dus (base),  and  cervix  (neck)  (see  Fig.  213). 

The  corpus  is  all  that  portion  of  the  organ 
lying  above  an  imaginary  plane,  passing 
through  the  vesical  openings  of  the  ureters 
and  the  center  of  the  symphysis  pubis.  That 
part  lying  below  this  plane  is  the  fundus  or 
base,  and  is  variously  divided.  The  portion 
which  lies  between  the  vesical  openings  of 
the  ureters  behind,  and  the  vesical  orifice  of 
the  urethra  in  front  (Fig.  214),  is  known  as 
the  trigone,  or  vesical  triangle.  That  portion 
of  the  base  lying  just  behind  the  ureteric 
openings  is  known  as  the  bas  fond.  This  is 
usually  but  a  slight  depression  in  early  and 
middle  life,  but  in  disease  and  advanced  age  it  often  becomes  a 
deep  pouch  or  sac.  This  is  more  often  the  case  in  the  male  than 
in  the  female.  The  cervix  or  neck  of  the  bladder  is  that  funnel- 
shaped  space  at  the  apex  of  the  trigone,  where  the  bladder  and  ure- 
thra merge  into  each  other. 

The  bladder  has  three  coats — two  complete  and  one  partial  or 
incomplete.  From  without  inward  these  are  the  serous  (incomplete), 
the  muscular,  and  the  mucous.  The  serous  investment  of  the  blad- 
der, like  that  of  all  the  abdominal  and  jDclvic  organs,  consists  of 
peritonaeum,  of  which  I  will  speak  more  fully  when  I  come  to  con- 
sider the  ligaments  and  topographical  relations  of  this  organ. 

The  middle  or  muscular  coat  has  a  peculiarly  efficient  fiber  ar- 
rangement. Its  layers  have  been  divided  into  two — external  and 
internal — but  so  frequent  and  so  intimate  are  their  interlacements 
that,  though  when  minutely  considered  they  are  two,  practically  they 
act  and  appear  as  one.     The  main  direction  of  the  outer  fibers  is 


Fig.  213. — Diagram  of  the 
bladder  to  show  corpus 
and  fundus. 


ANATOMY   OF   THE   BLADDER.  611 

longitudinal ;  of  the  inner,  circular.  There  is  also  a  thin  stratum 
of  muscular  fiber  lying  just  under  the  mucous  membrane,  and  con- 
tinuous with  the  longitudinal  fibers  of  the  urethra.  The  main  iibers 
are  of  the  unstriped  or  involuntary  kind,  and  take  their  origin  chiefly 
from  the  neck  of  the  bladder. 

According  to  some  authors,  the  sphincter  vesicae  is  formed  by  a 
strong  band  of  muscular  fibers,  varying  from  one  eighth  to  half  an 
inch  in  thickness.  By  others,  and  these  are  perhaps  the  best  au- 
thorities, it  is  claimed  that  there  is  no  true  anatomical  sphincter  of 
the  bladder.  The  function  of  the  sphincter  vesicae  is  said  to  be  per- 
formed by  the  closing  together  of  the  longitudinal  folds  of  the  tis- 
sues at  the  junction  of  the  bladder  and  urethra,  or  by  the  transverse 
semicircular  folds  that  close  over  each  other. 

At  the  base  of  the  bladder  two  httle  muscular  slips  arise  from 
the  portion  usually  designated  as  the  sphincter  vesicae,  and  find  in- 
sertion about  the  vesical  openings  of  the  ureters.  These  muscular 
fasciculi  are  but  imperfectly  developed  in  the  female,  and  probably 
have  little  if  any  specific  action. 

The  lining  or  mucous  coat  of  the  bladder  is  like  that  of  the  ure- 
ters and  urethra.  It  consists  of  a  basement  membrane,  supporting 
two  or  more  layers  of  epithelium,  in  some  parts  squamous,  in  others 
cylindrical,  the  whole  lying  upon  an  elastic,  cellulo-vascular  bed  that 
is  fitted  into  the  meshes  of  the  reticulated  muscular  coat  beneath. 

This  mucous  membrane  is  nowhere  attached  closely  to  the  sub- 
jacent muscular  layer,  save  at  the  trigone,  the  neck,  and  about  the 
orifices  of  the  ureters.  Owing  to  the  general  looseness  of  attach- 
ment when  the  bladder  is  partially  or  wholly  contracted,  the  mucous 
membrane  is  thrown  into  rough,  uneven  folds  everywhere,  save  at 
the  points  of  close  attachment  already  mentioned. 

In  the  trigonal  space  the  membrane  is  thinner,  more  closely  ad- 
herent, and  the  surface  epithelium  is  usually  of  the  medium-sized, 
squamous  variety.  The  nerve-supply  to  this  small  space  is  very 
rich,  and,  in  consequence,  it  is  the  most  sensitive  part  of  the  blad- 
der. 

Although  Savage  denies  the  presence  of  glands  or  papillae  in  the 
raucous  membrane  of  the  bladder,  Holden  and  many  others  main- 
tain (and  correctly,  I  think)  that  the  membrane  is  studded  with 
numerous  little  glands  and  follicles,  whose  function  is  to  supply 
mucus  to  the  internal  surface  of  the  organ.  They  are  most  numer- 
ous at  and  about  the  vesical  neck. 

The  trigone  in  the  female  is  a  smaller  space,  and  has  less  dis- 
tinctly marked  boundaries  than  in  the  male.     That  little  elevation 


G12 


DISEASES   OF   "WOMEN. 


of  uuieons  membrane  lying  at  the  very  apex  of  the  trigonal  space, 
and  known  as  the  nvula,  is  also  but  little  develoj^ed  in  the  fe- 
male. 

Running  between  the  vesical  orifices  of  the  ureters,  Jurie  claims 
to  have  found  what  he  calls  the  iuter-uretenc  ligameiit,  in  the  ends 
of  which  he  asserts  that  the  ureteric  orifices  are  imbedded.  To  its 
action  he  attributes  tlie  power  that  the  bladder  has  of  preventing 
regurgitation  into  the  ureters.  I  will  speak  more  fully  on  this  point 
presently. 

Normally,  the  bladder  has  thi'ee  openings,  one  for  each  ureter, 
and  the  urethral  orifice.  The  openings  of  the  ureters  lie  on  each 
side  of  the  median  line  at  the  l^ase  of  tlie  bladder,  about  one  inch 
and  a  half  behind  the  vesical  opening  of  the  urethra,  and  about  two 
inches  apart.  The  ureters  pierce  the  bladder- wall  obliquely,  and  their 
openings  are  so  minute  as  to  be  hardly  \dsible  to  the  naked  eye. 
Their  points  of  entrance  are  marked  by  a  slight  puckering  in  the 

mucous  membrane. 
The  third  opening  is 
the  ostium  urethrse 
internum,  which  is  a 
diagonal  slit  at  the 
juncture  of  the  vesi- 
cal neck  and  u  rot  lira. 
According  to  Ru- 
tenberg,  the  color  of 
the  vesical  mucous 
membrane  in  the  liv- 
ing subject  before 
dilatation  is  a  dull, 
grayish  red  ;  but,  as 
dilatation  proceeds, 
and  the  irregular 
folds  are  straightened 
out,  it  becomes  grad- 
ually a  brighter  red, 
and,  when  complete 
distention  is  accom- 
plished, the  minute 
arteries  can  be  seen 
forming  a  beautiful  interlacing  network  on  the  bands  of  the  muscu- 
lar reticulag.  "Whenever  it  has  been  my  good  fortune  to  see  this 
membrane  in  the  living  subject,  it  has  appeared  to  me  as  being  of  a 


Fig.  214. — Base  and  neck  of  the  bladder  (Savage),  a,  sym- 
physis pubis.  1,  1,  Ureters.  1',  Ureteric  openings. 
2,  3,  Uterine  artery  and  veins.  4,  Outline  of  cervix 
uteri.  5,  Vesical  neck.  6,  Arcus  tendineus  and  vesico- 
pubic muscles.     7,  7,  Pubo-coccygeus  muscles. 


ANATOMY   OF   THE   BLADDER.  613 

grayisli-pink  color,  not  unlike  that  of  tlie  iniicous  membrane  of  the 
cervix  uteri  when  anaeuiic. 

The  vascular  supply  of  the  bladder  is  very  free,  being  derived 
from  the  superior,  middle,  and  inferior  vesical  arteries,  and  branches 
from  the  uterine  artery.  They  all  arise  from  the  anterior  trunks  of 
the  internal  iliac  arteries.  The  anastomoses  of  the  arterial  twigs  are 
numerous  and  free.  The  veins  are  also  numerous  and  large,  form- 
ing by  interlacement  and  connection  thick,  tortuous  plexuses  about 
the  base,  sides,  and  neck  of  the  bladder,  and  finally  terminate  in  the 
internal  iliac  veins.  This  plexus  about  the  neck  of  the  bladder  com- 
municates freely  with  that  of  the  labia  minora,  uterus,  and  rectum. 
These  venous  plexuses  are  the  chief  elements  in  the  so-called  "haem- 
orrhoids of  the  bladder." 

In  their  tortuous  course  these  veins  are  accompanied  by  lym- 
phatics that  seem  to  have  their  origin  in  the  submucous  cellular 
tissue  of  the  bladder.  They  enter  the  glands  situated  about 
the  internal  iliac  artery,  and  from  there  go  to  the  lumbar 
glands. 

The  nerves  of  the  bladder  are  of  two  kinds — sj^inal  and  sympa- 
thetic. The  spinal  nerves  are  branches,  usually  from  the  fourth, 
sometimes  from  the  third,  and  rarely  from  the  second  sacral  nerve. 
They  terminate  chiefly  in  and  about  the  neck  and  base  of  the  blad- 
der. The  sympathetic  nerves  have  their  origin  from  the  hypogastric 
plexus,  which  lies  in  front  of  and  on  the  last  lumbar  and  first  sacral 
vertebrae.  It  is  formed  by  a  mazy  interlacement  of  numerous  gan- 
glionic fibers,  and  branches  from  the  spinal  nerves,  especially  the 
second  sacral.  Ganglia  are  common,  more  particularly  at  the  point 
of  junction  of  the  spinal  and  sympathetic  nerves.  This  plexus  sends 
branches  to  all  parts  of  the  bladder,  and  to  the  vagina,  uterus,  and 
rectum.  This  common  nerve-supply  to  the  various  pelvic  organs 
must  be  borne  distinctly  in  mind  in  order  that  the  functional  de- 
rangements and  neuroses  of  the  bladder,  hereafter  to  be  described, 
may  be  thoroughly  understood. 

Anatomy  of  the  Urethra. — The  female  urethra  is  a  musculo-mem- 
branous  canal,  from  one  to  two  inches  in  length,  the  average  being 
about  one  inch  and  three  eighths.  Its  diameter  is  greater  than  that 
of  the  male,  being  about  one  fourth  of  an  inch. 

It  lies  in  the  median  line,  just  under  the  pubic  arch,  and  is  held 
in  position  by  the  median  pubo-vesical  ligament.  In  the  erect  posi- 
tion it  has  a  direction  upward  and  backward,  and  at  all  times,  when 
normal,  its  axis  closely  coi-responds  to  that  of  the  pelvic  outlet.  It 
terminates  anteriorly  at  the  base  of  the  vestibule  by  an  ojiening 


614 


DISEASES  OF  WOMEN". 


k 


J 


known  as  the  meatus  urinarius,  and  posteriorly  at  the  neck  of  the 
bladder. 

It  has  a  cellular,  a  double  muscular,  and  a  mucous  coat.  Accord- 
ing to  Robin  and  Cadiat,  its  mucous  membrane  is  richer  in  elastic 
tissue  than  any  other  in  the  body.  The  epithelial  covering  of  the 
anterior  or  lowest  portion  is  of  the  pavement  variety,  and  closely 
resembles  that  of  the  vagina,  except  that  it  is  not  so  large.  Figs. 
217  and  218  show  the  difference  between  the 
1/^.  ^|s:  ^  two.  Posteriorly  and  superiorly  it  is  like  that 
"^  '  -^  ^  '  Q-f  ^]^Q  bladder  —  columnar  and  squamous. 
Scattered  throughout  are  little  papillae,  con- 
taining blood  -  vessels,  and  near  the  meatus 
there  are  numerous  lacunje  surrounded  by 
villous  tufts.  There  is  also  a  number  of  small 
mucous  glands,  that  in  old  people  often  con- 
tain black  particles,  like  the  j^rostatic  concre- 
tions of  the  male. 

Upon  each  side,  near  the  floor  of  the  fe- 
male urethra,  there  are  two  tubules  large 
enough  to  admit  a  No.  1  probe  of  the  French 
scale.  They  extend  from  the  meatus  urinari- 
us upward,  from  three  eighths  to  three  quar- 
ters of  an  inch.  Fig.  215  is  a  drawing  from 
a  section  of  the  urethra,  laid  open  by  division 
of  its  posterior  or  vaginal  wall.  The  tubules, 
having  been  distended  by  probes  passed  into  them,  are  plainly  seen. 
Fig.  216  shows  the  same  thing  from  the  opposite  side,  the  ure- 
thra having  been  laid  open  by  section  of  its  ante- 
rior wall.  The  space  between  the  tubules  is  the  |  ^  '''  \ 
floor  of  the  urethra.  From  these  it  will  be  ob-  , 
served  that  the  tubules  run  parallel  with  the  long 
axis  of  the  urethra. 

They  are  located  beneath  the  mucous  mem- 
brane in  the  muscular  walls  of  the  urethra. 
This  is  represented  by  Fig.  217,  which  is  a  draw- 
ing taken  from  a  transverse  section  of  the  ure- 
thra, about  a  quarter  of  an  inch  from  the  meatus. 
The  mouths  of  these  tubules  are  found  upon 
the  free  surface  of  the  mucous  membrane  of  the 
urethra,  within  the  labia  of  the  meatus  urinarius.  fig.  216.— Urethra  laid 
The  location  of  the  openings  is  subiect  to  slight         ^f  °  with  probes  in 

-■•  ="  .   .  •'  ^'^  Slvene's  glands  (an- 

variatiou,  according  to  the  condition  and  form         terior  wall  divided). 


Fig. 


215.  —  Urethra  laid 
open  with  probes  dis- 
tending the  glands  (pos- 
terior wall  divided). 


ANATOMY   OF   THE    URETHRA. 


615 


of  the  meatus.  In  some  subjects,  especially  the  young  and  very 
aged,  and  in  those  in  whom  the  meatus. is  small,  and  does  not  pro- 
ject above  the  plane  of  the  ves- 


tibule, the  oritices  are  found 
about  an  eighth  of  an  inch  with- 
in the  outer  border  of  the  mea- 
tus. When  the  mucous  mem- 
brane of  the  urethra  is  thickened 
and  relaxed,  so  as  to  become 
slightly  pi'olapsed,  or  when  the 
meatus  is  everted,  conditions  not 
uncommon  in  those  who  have 
borne  children,  the  openings  are 
exposed  to  view  upon  each  side 
of  the  entrance  to  the  urethra. 
What  is  here  described  is  rep- 
resented in  Fig.  219.  The  labia 
of  the  meatus  have  been  slight- 
ly everted  to  bring  the  orifices 
into  view. 

The  upper  ends  of  the  tu- 
bules terminate  in  a  number  of 
divisions,  which  branch  off  into 
the  muscular  walls  of  the  ure- 
thra. By  injecting  one  of  the 
tubules  with  mercury,  and  then  dividing  it,  the  openings  of  the 
branches  can  be  easily  seen. 

This  description  of  the  anatom.y  of  these  glands  is  taken  from 
dissections  and  microscopical  examinations  made  by  Drs.  B.  F,  West- 
brook  and  J.  M.  Van  Cott,  Jr.  I  have  called  them  glands  because 
they  differ  in  size  and  structure  from  the  simple  follicles  found  in 
abundance  in  the  mucous  membrane. 

When  I  first  discovered  these  glands  I  presumed  that  they  were 
mucous  folKcles  that  were  accidentally  of  unusual  size  in  the  subject 
examined,  but,  having  investigated  more  than  one  hundred  of  them 
in  as  many  different  subjects,  and  finding  them  constantly  present, 
and  so  uniform  in  size  and  location,  I  became  satisfied  that  they  were 
worthy  of  a  separate  place  in  descriptive  anatomy.  The  dissections 
made  by  Dr.  Westbrook,  and  the  pathological  lesions  to  which  these 
structures  are  subject,  confirm  this  belief. 

So  far  as  I  know,  the  anatomy  of  these  glands  has  not  been  de- 
scribed, nor  have  the  diseases  to  which  they  are  subject  been  referred 


Fig.  21*7. — Transverse  section  of  urethra  with 
irland  on  either  side. 


616 


DISEASES   OF   WOMEN. 


to  by  pathologists.  At  least  tliis  much  may  be  said,  that  the  stand- 
ard text-books  on  anatomy  and  gynecology  in  English,  German,  and 
French  contain  no  reference  to  them. 

It  is  easy  to  understand  why  these  insignificant  glands  should 


1    \  k\«i.N«n^^- 


Fig.  218. — Longitudinal  section  of  urethral  glands. 

have  been  overlooked  by  anatomists,  or,  if  noticed  at  all,  classed  with 
other  mucous  follicles.  It  is  only  when  their  pathology  is  under- 
stood that  their  real  importance  becomes  appai*ent. 

I  know  nothing  about  their  physiology.  They  serve  some  pur- 
pose in  the  economy,  no  doubt,  but  what  is  their  function  is  a  ques- 
tion to  be  answered  in  the  future.  This  will  doubtless  be  attended 
to  at  an  early  date,  as  the  subject  is  worthy  of  investigation.  The 
pathology  of  these  glands,  so  far  as  has  been  investigated  up  to  this 
time,  is  of  great  practical  interest,  and  there  remains,  no  doubt,  much 
still  to  be  studied.  Clinical  observation  has  already  shown  that 
they  are  subject  to  inflammation  of  various  degrees  of  intensity 
and  duration. 

The  meatus  urinarius  in  the  female  differs  from  that  of  the  male 
in  being  a  puckered  and  somewhat  prominent,  rather  than  a  slit-like 


ANATOMY   OF  THE   UEETHRA. 


61' 


A 


s.^nt 


The  meatus  everted, 
showing  the  mouths  of  the 
glands. 


and  depressed  opening.     The  mucous  membrane  of  the  urethra  is 
thrown  into  longitudinal  folds  throughout,  save  when  opened  and 
unwrinkled  during  micturition  or  by  arti- 
ficial  dilatation.     When   at   rest   it   is   a 
closed  canal. 

Beneath  the  mucous  membrane  there 
is  a  thick  fibro-elastic  network  into  which 
the  mucous  glands  dip.  These  are  lined 
with  cylindrical  epithelium  and  surrounded 
by  a  network  of  veins.  This  submucous 
areolar  tissue  has  direct  vascular  connec- 
tion with  the  muscular  layer  that  sur- 
rounds it  by  means  of  cavernous  venous  si- 
nuses, partly  in  the  muscle  and  partly  in 
the  elastic  connective  tissue.  Thus  there 
is  an  arrangement  almost  exactly  like  that 
of  the  corpus  cavernosum  penis  in  the 
male.  The  venous  plexus  of  the  urethra 
is  situated  chiefly  at  the  sides,  in  what  is  Fig.  219. 
known  as  the  urethro-pubic  space. 

The  muscular  layer  is  double,  the  outer 
portion  being  composed  of  both  circular  and  spiral  fibers  mixed,  and 
the  inner  of  longitudinal  fibers  only,  and  these  two  layers  are  so 
closely  bound  together  by  the  cavernous  venous  sinuses  as  to  be  in 
reality  but  one.  Dr.  Uffleman  claims  to  have  found  an  additional 
external  layer,  the  fibers  of  which  are  voluntary.  He  divides  this 
layer  into  two — an  external  and  an  internal — the  former  longitud- 
inal, the  latter  transverse.  These  make  what  he  calls  the  outer  or 
voluntary  sphincter  of  the  bladder.  From  the  vesical  neck  to  a 
point  about  half-way  down  it  wholly  invests  the  urethra,  forming 
only  a  partial  investment  from  that  point  to  the  meatus. 

Luschka  claims  to  have  found  a  sphincter  of  the  urethra  and 
vagina.  He  describes  it  as  being  smooth  and  circular,  from  one 
sixth  to  one  third  of  an  inch  broad,  lying  directly  behind  the  vesti- 
bule, and  girdling  both  the  vagina  and  urethra.  Its  function,  he 
says,  is  to  close  the  urethra  by  pressing  it  against  the  urethro-vagi- 
nal  septum.  Being  closely  adjacent  to  the  cavernous  venous  tissue 
of  the  urethra,  it  locks  its  fibers  posteriorly  with  those  of  the  mus- 
culus  transversus  profundus. 

In  the  female  as  in  the  male,  the  urethra  pierces  the  triangular 
subpubic  ligament,  two  layers  of  which  extend  around  it ;  one  back- 
ward and  the  other  forward. 


618  DISEASES  OF   WOMEN. 

There  is  great  diversity  of  opinion  as  to  the  nature  of  the  vesi- 
cal opening  of  the  urethra  in  the  female.  According  to  Winckel 
and  Simon  it  is  a  diagonal  slit,  the  mucous  membrane  of  which  is 
longitudinally  and  superficially  corrugated.  According  to  Savage, 
it  is  a  triangular  opening ;  and  according  to  Holden  and  others,  a 
funnel-shaped  opening.  It  of  course  varies  somewhat  with  age,  size 
of  urethra,  vesical  contraction,  or  quiescence,  and  in  the  li\nng  and 
dead  subject ;  and  hence  the  diverse  opinions  of  the  various  ob- 
servers. 

Anatomical  Relations  of  the  Bladder  and  Urethra. — Having  dis- 
cussed the  anatomy  of  the  bladder  and  urethra,  it  remains  to  exam- 
ine the  topographical  relations  of  these  organs.  This  is  very  neces- 
sary to  a  proper  understanding  of  the  influence  of  other  organs  in 
causing  diseases  and  displacements  of  the  bladder  and  urethra. 

The  bladder  of  the  female  lies  lower  in  the  pelvis  than  that  of 
the  male,  between  the  pubes  anteriorly,  the  uterus  posteriorly,  the 
vagina  and  uterine  cervix  inferiorly,  and  the  small  intestines  superi- 
orly. The  organ  when  empty  lies  behind  the  symphysis  pubis,  its 
highest  point  slightly  overtopping  it.  In  this  position  it  occupies 
but  httle  space.  When  partially  or  wholly  tilled  it  rises  above  the 
pubes  to  a  varying  extent.  In  doing  this  it  alters  but  slightly  the 
position  of  the  other  pelvic  viscera,  although  relatively  its  position 
is  somewhat  changed. 

Anteriorly  the  bladder  is  separated  from  the  posterior  face  of 
the  pubic  symphysis  by  intervening  cellular  tissue,  Inferiorly  it 
forms  a  close  attachment  to  the  anterior  vaginal  wall  by  means  of  a 
dense  cellular  cushion  which  increases  in  thickness  from  before  back- 
ward. The  bladder  rests  upon  this  vesico- vaginal  septum  as  far  up 
as  the  point  where  the  body  and  neck  of  the  uterus  join  each  other. 
Posteriorly  and  somewhat  superiorly  to  the  bladder  lies  the  uterus, 
and  superiorly  and  postero-laterally  are  the  ovaries  and  broad  liga- 
ments. 

The  close  attachment  of  the  vesical  neck  to  the  arch  of  the  pubes, 
by  the  pubic  ligament  anteriorly  and  the  vagina  inferiorly,  makes  a 
kind  of  wedge  that  gives  but  little  surface  for  bagging  do^vnward 
if  the  vagina  holds  its  proper  position.  Though  imperfectly,  still  to 
a  certain  extent,  this  arrangement  resembles  the  perinasum  in  the 
male.  Superiorly,  the  organ  is  held  in  position  by  a  number  of 
ligaments ;  five  false  and  five  true.  The  false  ligaments  (one  supe- 
rior, two  lateral,  and  two  posterior),  are  formed  of  peritonaeum. 
This  membrane  is  reflected  from  the  inner  face  of  the  anterior  ab- 
dominal wall  to  the  bladder  investing  it  superiorly,  laterally,  and,  to 


KELATIONS   OF  THE  BLADDER  AND   URETHRA.  619 

a  certain  extent,  posteriorly.  It  joins  the  organ  in  front,  dipping 
down  just  above  the  pubic  summit  to  the  superior  vesical  surface, 
and  passes  as  far  backward  as  the  point  of  contact  between  the  vesi- 
cal base  and  uterus,  which  is  at  the  junction  of  the  uterine  body  and 
cervix.  Although  this  peritoneal  covering  of  the  bladder  is  lirnily 
adherent,  it  never  leaves  its  uterine  or  other  attachments,  however 
much  the  bladder  may  be  distended  and  rise  above  the  brim  of  the 
pelvis. 

That  portion  of  the  bladder  lying  behind  the  pubes,  that  resting 
on  the  vagina  and  uterine  neck,  and  a  small  posterior  and  lateral 
portion  have  no  serous  investment. 

The  true  ligaments  are  also  five  in  number — two  anterior  or 
vesico-pubic,  two  lateral,  and  the  superior  or  urachus  cord. 

Laterally,  the  round  ligaments  of  the  uterus  pass  over  the  blad- 
der-wall, and  just  below  and  posteriorly  the  ureters  enter  that 
organ. 

These  ducts,  the  excretory  ducts  of  the  kidneys,  are  usually  de- 
scribed as  passing  downward,  forward,  and  inward,  after  entering 
the  cavity  of  the  pelvis,  to  the  base  of  the  bladder,  and  after  passing 
for  an  inch  between  the  muscular  coats  of  that  organ  opening  into 
it  by  constricted  orifices.  In  their  course  they  pass  along  the  sides 
of  the  cervix  uteri  and  upper  part  of  the  vagina,  and  at  their  points 
of  entrance  into  the  bladder  are  from  one  half  to  three  quarters  of  an 
inch  in  front  of  the  cervix  uteri.  It  is  very  important  that  the  re- 
lation of  the  ureters  to  the  bladder  should  be  borne  in  mind,  espe- 
cially in  the  operation  of  gastro-elytrotomy.  Garrigues,  who  has  in- 
vestigated this  point,  says :  "  The  ureter  does  not  lie  in  the  broad  liga- 
ments, it  does  not  keep  the  same  direction  on  reaching  the  wall  of 
the  bladder,  and  it  does  not  lie  close  up  to  the  wall  of  the  cervix,  as 
taught  by  anatomical  authorities.  After  having  crossed  the  iliac 
vessels  the  ureters  diverge,  running  dowmward,  backward,  and  a  lit- 
tle outward  on  the  wall  of  the  pelvis,  behind  the  broad  ligaments  to 
a  point  near  the  spina  ischii.  Then  they  lead  downward,  forward, 
and  considerably  inward  so  as  to  converge  toward  the  bladder.  They 
pass  beneath  the  base  of  the  broad  ligament,  lying  in  the  abundant 
cellular  tissue  found  in  this  locality.  They  cross  the  cervix  at  some 
distance  from  behind,  at  an  acute  angle,  so  as  to  come  in  front  of 
and  below  it.  They  lie  outside  and  above  the  anterior  part  of  the 
side  wall  of  the  vagina  on  a  spot  as  large  as  the  tip  of  the  finger. 
On  reaching  the  wall  of  the  bladder  they  turn  rather  sharply  inward 
and  go  downward  until  they  open  with  a  small  slit  into  the  inte- 
rior of  the  bladder  at  the  outer  angle  of  the  trigonum  vesicae.     But 


620 


RELATIONS  OF  THE  BLADDER  AND  URETHRA. 


on  dissecting  the  bladder  from  the  nterus  and  vagina  their  substance 
is  seen  to  continue  as  a  sohd  ridge  bstweeu  the  two  apertures,  and 
forming  the  base  of  the  trigone  (Jurie's  inter-ureteric  ligament.)  " 

The  illustration  of  Gar- 
rigues  makes  this  descrip- 
tion very  clear  (Fig.  220.) 
Just  in  front  of  the 
small  lateral  space  lacking 
serous  investment  the  ob- 
literated umbihcal  arteries 
pass  uj)ward  and  forward 
to  the  summit  of  the  blad- 
der reflecting  the  perito- 
nseum,  and  thus  fonning 
a  double  pouch  on  either 
side. 

The  relations  of  the 
m'ethra  are  as  follows :  it 
lies  just  under  the  pubic 
symphysis,  and,  piercing 
the  deep  perineal  fascia, 
extends  from  the  vesical 
neck,  at  the  ostium  ure- 
three  internum,  to  the  meatus  urinarius  or  ostium  urethrse  externum, 
situate  at  the  base  of  the  triangular  space  known  as  the  vestibule. 
Its  anterior  three  fourths  are  imbedded  in  the  vaginal  wall.  The 
meatus  urinarius  lies  about  four  fifths  of  an  inch  below  the  clitoris, 
in  the  vaginal  margin  of  the  vestibule.  The  vesical  end  of  the 
urethra  is  about  the  same  distance  below  the  lower  surface  of  the 
pubic  symphysis.  Its  course  is  upward  and  backward  forming  a 
very  slight  curve. 

Development  of  the  Bladder  and  Urethra. — With  this  brief  sketch 
of  the  structure  of  the  bladder  and  urethra  their  development  may 
be  next  considered.  It  would  be  very  interesting,  from  a  scientific 
point  of  view,  to  examine  the  process  by  which  the  bladder  and 
uretlira  are  formed  in  the  embryo  ;  but  it  would,  I  think,  be  rather 
tedious  to  take  up  the  subject  in  all  its  minutiae.  A  few  of  the 
more  important  points  in  the  process  of  development  must  l)e  un- 
derstood, however,  in  order  to  comprehend  the  malformations  which 
are  occasionally  met  with.  Most,  or  at  least  many,  of  the  malfor- 
mations of  the  urinary  apparatus,  like  those  of  other  organs  are  due 
to  arrest  of  development  at  various  stages  of  that  process.     A  clear 


Fig.  220. — The  relations  of  the  ureters  (Garrigues). 
u,  uterus  ;  b,  bladder ;  wr,  ureter  ;  u,  urethra ; 
T,  vagina ;  f,  Fallopian  tube ;  0,  ovary  ;  b,  broad 
ligament ;  >%  round  ligament. 


DEVELOPMENT   OF   THE   BLADDER   AND    URETHRA.        621 

conception  of  the  normal,  therefore,  will  aid  in  better  understanding 
the  abnormal. 

The  urinary  organs  are  developed  in  separate  portions  or  sec- 
tions having  distinct  points  of  origin,  and  by  the  union  and  fusion 
of  these  parts  the  entire  apparatus  is  completed. 

The  bladder  is  formed  from  a  portion  of  the  allantois.  When 
the  abdominal  plates  of  the  embryo  close  around  that  portion  of  the 
allantois  that  forms  the  umbilical  cord,  they  also  shut  in  a  portion 
which  forms  the  urinary  bladder.  There  remains,  for  a  time,  a  di- 
rect communication  between  that  portion  of  the  allantois  from  which 
the  bladder  is  formed  and  that  which  makes  the  cord,  which  takes 
the  name  of  the  urachus.  The  canal  or  duct  in  the  urachus  is  usu- 
ally obliterated  before  or  soon  after  birth,  so  that  all  that  remains  of 
it  is  an  impervious  cord  known  as  the  superior  vesical  ligament.  It 
will  thus  he  seen  that  the  bladder  is  developed  from  the  allantois, 
which  may  be  called  one  center  of  development  for  the  urinary  ap- 
paratus. 

The  centers  of  development  for  the  ureters  are  the  same  as  those 
for  the  kidneys.  Indeed,  the  ureters  are  processes  that  are  developed 
from  the  kidneys,  and  extend  downward  until  they  unite  with  the 
bladder,  and  finally  open  into  it. 

While  the  bladder  and  ureters  are  being  thus  formed,  the  lower 
portion  of  the  alimentary  canal — that  which  forms  the  rectum — be- 
comes separated  from  the  section  of  the  allantois  that  forms  the 
bladder.  Into  this  space,  between  the  rectum  and  bladder,  Miiller's 
ducts  descend,  and,  uniting,  form  the  vagina  (see  Figs.  53-57). 

Posterior  to  Miiller's  ducts  and  anterior  to  the  rectum,  a  mass  of 
tissue  is  developed  which  helps  to  form  the  recto-vaginal  wall  above 
and  the  perinseum  below. 

Anteriorly  Miiller's  ducts  unite  with  the  lower  portion  of  the 
bladder,  and  aid  in  the  formation  of  the  urethra,  or,  at  least,  the  up- 
per portion  of  its  posterior  wall. 

The  lower  or  external  portions  of  the  genito-urinary  organs  are 
formed  from  an  ovoid  eminence  which  appears  in  the  median  line 
of  the  lower  anterior  part  of  the  trank  of  the  embryo.  At  the  lower 
part  of  this  eminence  there  appears  a  fissure,  which,  incurvating  and 
uniting  with  the  lower  portion  of  Miiller's  ducts  (vagina)  forms  the 
terminal  portion  of  the  urethra  and  the  introitus  vagiuse.  From  this 
same  center  of  development  the  labia  majora,  the  labia  minora,  and 
the  vestibule  are  formed. 


CHAPTER  XXXV. 

MALFOKMATIONS    OF   THE   BLADDER   AND    URETHRA. 

Malformations  of  the  Urethra. — Malformations,  as  has  already  heen 
said,  are  usually  the  result  of  arrested  development.  Yarious  fail- 
ures in  the  processes  necessary  to  form  the  complete  urethra  result 
in  a  number  of  malformations.  The  most  important  of  these  may 
be  classified  as  follows : 

1.  Defectus  ure three  totalis. 

2.  Defectus  urethrse  externus. 

3.  Defectus  urethras  internus. 

4.  Atresia  urethrfie. 

In  the  first  form  (defectus  urethree  totalis)  there  is,  as  the  term 
implies,  entire  absence  of  the  urethra.  It  is  said  to  be  due  chiefly 
to  an  ari'est  in  the  development  of  the  vagina  at  a  point  where  it 
should  form  the  main  portion  of  the  posterior  wall  of  the  m'ethra. 
It  is  very  probable  that  there  is  also  an  arrest  of  development  of 
the  clitoral  process. 

Coexisting  with  this  malformation  other  developmental  defects 
are  generally  but  not  invariably  found,  for  it  has  been  known  to  exist 
with  an  otherwise  perfect  genito-urinary  apparatus.  Petit  tells  of  the 
case  of  a  child,  four  years  old,  who  had  neither  urethra,  clitoris,  nor 
nymphse,  but  had  a  comj^aratively  wide  vagina.  Langenbeck  men- 
tions the  case  of  a  girl,  nineteen  years  of  age,*in  whom  the  bladder 
and  vagina  formed  a  common  canal.  She  was  incontinent  up  to  the 
age  mentioned,  and  is  reported  to  have  gained  control  of  the  bladder 
afterward. 

The  second  deformity  (defectus  urethrae  externus)  is  due  to  the 
absence  of  the  lower  and  anterior  portion  of  the  urethra.  It  has 
been  called  "  hypospadias  in  the  female."  One  of  the  most  marked 
cases  has  been  recorded  by  Von  Mosengeil.  The  subject  was  a  girl 
eight  years  old.  The  opening  in  the  urethra  was  situated  below  a 
large  clitoris,  having  a  very  full  prepuce.     It  was  much  higher  than 


MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA.   623 

the  normal  situation  of  the  meatus  urinarius.  There  was  a  groove 
running  from  the  lower  border  of  the  vestibule  up  to  the  opening  of 
the  urethra,  and  it  appeared  to  be  formed  from  the  anterior  wall  of 
the  urethra.  The  upper  portion  of  the  urethra  held  its  noraial  rela- 
tions to  the  bladder  and  vagina,  but  was  only  half  an  inch  in  length. 
The  bladder,  in  comparison  with  the  other  organs,  was  larger,  and 
had  a  number  of  saccules.  It  will  be  observed  that  in  this  case 
the  upper  portion  of  the  urethra  was  complete,  and  that  there  were 
present  in  the  lower  portion  of  the  canal  an  anterior  and  two  rudi- 
mentary lateral  walls,  the  posterior  wall  alone  being  absent. 

There  is  another  form  of  defectus  urethrse  externus  or  hypos- 
padias, in  which  the  lower  part  of  the  canal  is  entirely  wanting.  In 
such  cases  there  is  but  one  opening  between  the  clitoris  and  peri- 
nseum,  and  but  one  canal,  this  dividing  into  vagina  and  urethra  at 
some  distance  from  the  outer  opening.  An  interesting  example  of 
this  w^as  observed  by  Willigk,  in  a  woman,  who  died  at  the  age  of 
forty-six.  The  uro-genital  canal,  at  its  opening,  was  about  the  size 
of  a  catheter,  and  ran  in  a  curved  direction  under  the  pubes.  About 
an  inch  and  a  half  from  its  outer  opening  it  divided  into  two  pass- 
ages, one  anteriorly,  V  long — the  urethra,  and  one  posteriorly,  2" 
to  10''  long — the  vagina. 

The  third  deformity  (defectus  urethrse  internus)  is  that  in  which 
the  internal  or  upper  portion  of  the  urethra  is  wanting,  and  is  a 
comparatively  rare  affection.  The  only  cases,  so  far  as  I  know,  are 
given  by  Oberteufer  and  Duparcque.  In  Oberteufer's  case,  as  I 
understand  it,  the  lady  was  forty-two  years  of  age,  and  all  her  life 
had  passed  water  from  the  umbilicus.  Her  vagina  was  normal,  and 
so  were  the  external  genital  organs.  The  upper  or  internal  portion 
of  the  urethra  alone  was  wanting.  Duparcque's  case  was  one  in 
which  the  urethra  was  pervious  as  far  as  the  bladder,  but  was  there 
closed.  This  case,  however,  appears  to  me  more  properly  to  come 
under  the  head  of  atresia  urethr^e. 

The  fourth  class  (atresia  urethrse)  is  a  comparatively  common 
affection.  There  are  two  forms  of  congenital  atresia  mentioned  by 
authors.  The  first  is  produced  by  imperfect  development  of  the 
vaginal  process,  or  of  both  the  clitoral  and  vaginal  segments.  Du- 
parcque's case  was  of  this  kind,  the  urethra  being  open  up  to  the 
bladder  and  there  closed.  It  was  a  form  of  defectus  urethrsB  in- 
ternus witli  atresia  at  the  upper  end  of  the  canal.  In  this  case  the 
bladder  and  ureters  were  greatly  distended. 

The  other  form  of  atresia  is  found  when  the  clitoral  and  vagi- 
nal processes  are  both  defective.     In  such  cases  there  is  no  trace  of 


G24  DISEASES  OF   WOMEN. 

a  urethra,  except  an  imperfect  vaginal  wall  which  extends  obliquely 
downward  and  closes  the  bladder.  E.  Rose  relates  a  case  of  this 
kind  in  which  the  bladder,  kidneys,  and  abdomen  were  filled  with 
water.  The  urethral  malformation  was  not  the  only  one  in  this  case, 
the  vagina  and  uterus  suffered  from  an  arrest  of  development  and 
were  both  double  or  rudimentary. 

Before  leaving  this  interesting  subject  I  w^ill  mention  another 
rare  malformation.  It  is  an  obstructive  anomaly,  and  consists  in  a 
double  condition  of  the  urethra.  The  only  case,  so  far  as  I  know, 
which  has  been  described  with  any  accuracy,  is  that  of  Furst.  He 
observed  in  a  preparation  taken  from  the  body  of  a  young  virgin  the 
following  peculiarities  :  In  looking  at  the  anterior  bladder-wall  at 
the  first  glance  only  one  urethral  orifice  was  to  be  seen,  but  one 
tenth  of  an  inch  forward  toward  the  meatus  the  single  urethra  was 
seen  to  bifurcate ;  a  fine  septum,  nearly  straight,  divided  it  from 
right  to  left  into  an  anterior  and  posterior  half ;  these  continued 
with  an  ever  enlarging  and  diverging  septum  until  they  opened  into 
the  vagina  about  one  tenth  of  an  inch  apart.  In  this  Avay  they 
twisted,  so  that  the  anterior  or  superior  one  opened  toward  the  right, 
while  the  posterior  (the  one  in  the  region  of  the  bladder)  opened 
into  the  vagina  on  the  left.  The  left  urethra  opened  with  a  caliber 
of  one  fifth  of  an  inch  into  the  median  line  of  the  vagina.  The  right 
ojDened  on  the  right  of  the  median  line,  having  a  caliber  of  only  one 
tenth  of  an  inch.     The  length  of  the  whole  urethra  was  one  inch. 

It  is  of  very  rare  occurrence  that  the  double  condition  of  the 
allantois  persists  in  this  manner,  and,  considering  all  the  changes 
that  the  sinus  uro-genitalis  has  to  undergo,  it  seems  strange  that 
blending  did  not  take  place.  It  is  also  interesting  from  the  fact 
that  the  allantoic  openings  into  the  cloaca  can  only  take  place  by  a 
very  rapid  and  early  interruption  of  development.  The  uterus  and 
vagina,  in  this  case,  were  perfectly  normal. 

Symptomatology  of  Malformation  of  the  Urethra. — The  symptoms 
that  arise  from  malformation  of  the  urethra  arc  incontinence  in  the 
one  class  of  cases,  and  retention  of  urine  in  the  other.  When  the 
urethra  is  deficient  in  part  and  the  bladder  perforate,  urine  con- 
stantly escapes  ;  and  from  the  wetting,  the  excoriation,  and  the  odor, 
the  unfortunate  subject  is  kept  in  continual  misery. 

In  eases  where  there  is  an  abnormal  contraction  of  the  vagina 
the  urine  can  be  retained,  partially  at  least.  This  is  supposed  to  be 
effected  by  the  small  size  of  the  genito-urinary  sinus,  and,  possibly, 
a  voluntary  contraction  of  the  sphincter  vaginte  muscle  which  may 
act  as  a  sort  of  sphincter  and  aid  in  the  retention  of  urine. 


MALFORMATIONS   OF  THE   BLADDER   AND   URETHRA.      025 

Atresia  of  the  urethra  and  the  consequent  retention  of  tlie  urine 
cansc  hydrops  of  the  bladder,  ureters,  and  kidneys,  and  also  ascites, 
as  has  already  been  mentioned.  Distention  of  these  organs  occurs 
in  utero^  and  such  malformed  children  are  usually  born  dead,  or  die 
soon  after  birth.  So  great  is  this  distention  of  the  bladder  and  al)- 
domen  in  some  cases  that  delivery  is  difficult  or  impossible  until 
the  fluid  is  evacuated  by  puncture.  I  remember  seeing  one  such 
case.  The  head  was  delivered,  but  there  was  great  difficulty  in  de- 
livering the  body.  The  abdomen  was  enormously  enlarged  by  the 
overdistention  of  the  urinary  organs.  The  child  was  very  feeble, 
and  after  moaning  for  a  few  hours,  died.  No  effort  to  relieve  the 
bladder  was  made  because  a  diagnosis  was  not  reached  until  the  lit- 
tle one  was  dead. 

This  malformation  usually  leads  to  fatal  results,  and  our  knowl- 
edge avails  us  little  save  in  accounting  correctly  for  the  cause  of 
death.  The  only  natural  way  that  the  evil  effects  of  this  malforma- 
tion can  be  obviated  is  by  the  occurrence  of  another  developmental 
anomaly,  viz.,  fistula  of  the  urachus,  the  urine  then  escaping  from 
the  umbilicus.  Atresia  is  an  undoubted  factor  in  the  production  of 
urachal  fistula.  I  shall  speak  more  fully  of  this  when  I  come  to 
consider  vesical  malformations. 

When  defectus  urethrse  externus  occm's  in  patients  whose  uro- 
genitals are  otherwise  normal,  the  function  of  the  bladder  and  re- 
productive organs  may  all  be  performed  easily  and  uninterruptedly. 
Coitus  has  been  possible,  and  conception  has  been  known  to  occur 
in  such  cases. 

Diagnosis. — In  making  a  diagnosis  of  these  defonnities  reliance 
can  not  be  placed  on  the  symptoms  alone.  A  physical  examination 
of  the  parts  is  necessary.  The  general  relative  appearance  of  the 
external  organs  must  be  observed,  and  if  the  vagina  is  large  enough 
to  admit  the  speculum  it  should  be  used,  and  if  there  is  any  malfor- 
mation internally  it  can  easily  be  discovered  and  its  exact  location 
and  nature  ascertained.  There  is  usually  very  little  trouble  with 
such  cases,  but  where  the  entrance  to  the  vagina  is  so  narrow  that 
it  will  not  admit  a  sound  or  speculum,  the  diagnostic  skill  of  the 
physician  will  be  severely  taxed.  Such  cases  resemble  imperforate 
hymen,  or  acquired  atresia  of  the  vulva,  and  one  case,  at  least,  has 
been  mistaken  for  an  hermaphrodite.  Under  such  circumstances  an 
attempt  should  be  made  to  pass  the  sound  into  the  bladder,  and  by 
introducing  the  finger  or  another  sound  into  the  rectum  the  pres- 
ence or  absence  of  a  vagina  may  possibly  be  made  out.  If  the 
patient  is  an  adult,  and  the  case  one  of  imperforate  hymen,  meu- 
41 


626  DISEASES  OF   WOMEN. 

strual  fluid  will  probably  be  found  in  the  va£:ina.  Should  there  still 
remain  any  doubt,  the  only  resource  would  be  to  try  dilatation  of 
the  introitus  vaginas,  and  see  what  lies  beyond  it. 

Treatment. — The  treatment  may  be  either  radical  or  palliative. 
Where  there  is  an  entire  absence  of  the  urethra,  with  the  existence 
of  vesical  fissure,  or  in  persistence  of  the  sinus  uro-genitalis  with 
partially  developed  urethra,  the  pi'oduction  of  an  artificial  canal  has 
been  suggested.  This  may  be  done  by  dissecting  from  the  vaginal 
wall  a  flap  from  under  the  symphysis.  It  should  be  about  one  third 
of  an  inch  in  breadth,  and  after  being  turned  with  its  epithelial  sur- 
face inward,  should  be  united  with  the  freshened  edges  of  the  vesi- 
cal fissure.  It  is  objected  by  some  authors  that  even  if  the  opera- 
tion is  successful,  the  patient  will  be  but  little  benefited,  the  new 
urethra  being  devoid  of  muscular  tissue,  and  consequently  lacking 
the  power  of  contraction.  The  passing  of  urine  into  the  vagina, 
however,  will  be  done  away  with,  and  the  general  condition  of  the 
patient  will  be  greatly  improved  by  the  use  of  an  artificial  urinal. 
This  of  itself  is  a  great  point  in  favor  of  the  operation. 

Heppner  believes  that  the  method  of  producing  an  artificial  ure- 
thra by  trocar  puncture  of  the  soft  tissues  and  sewing  up  the  vesical 
fissure  is  dangerous,  because  vessels  of  considerable  size  are  liable 
to  be  injured ;  a  further  disadvantage  being  that  the  canal  tends  to 
dose.  The  cases  of  Carbol  and  Middleton  bearing  on  this  point  he 
puts  aside  as  unreliable.  He  moreover  maintains  that  reduction  of 
the  vesical  fissure  to  the  size  of  the  urethra  is  a  disadvantage,  since 
the  anterior  wall  of  the  fissure  will  be  without  any  muscular  tissue. 
The  experience  of  those  who  have  treated  fistula  has  1  )een,  so  far  as 
he  knows,  that  linear  clefts,  even  of  greater  caliber,  hold  back  the 
urine  better  than  round  openings  of  smaller  size,  the  former  allow- 
ing more  complete  coaptation  of  the  edges. 

In  Heppner's  case,  there  being  only  nocturnal  incontinence,  he 
contented  himself  \vith  applying  a  bandage  in  the  manner  suggested 
by  Sawostitzki.  A  girdle  was  put  around  the  lower  part  of  the  ab- 
domen, and  to  it  was  fastened  a  little  olive-shaped  compress,  by 
means  of  a  steel  spring,  something  after  the  manner  of  a  truss. 
When  put  into  the  vagina  this  compress  pushed  the  posterior  vesi- 
cal wall  toward  the  pubic  symphysis,  thus  closing  the  opening  and 
reheving  the  incontinence.  The  patient  soon  became  used  to  the 
instrument,  and  obtained  great  relief  from  it. 

Atresia  of  the  urethra  can  only  be  cured  by  operation.  Carbol 
operated  in  1550  on  a  servant-girl  in  Beaucaire,  who  had  suffered 
from  this  difficulty  from  her  youth  up.     The  urine  flowed  from  a 


MALFORMATIONS   OF  THE   BLADDER   AND   URETHRA.      627 

coxcomb-like  growth,  some  four  fingers  in  length,  at  the  umbilicus. 
The  stench  that  arose  from  her  body  was  intolerable.  Carbol  per- 
forated in  the  i-egion  of  the  urethra,  and  successfully  removed  the 
growth  at  the  umbilicus  by  ligation. 

In  the  case  of  a  child,  seven  days  old,  who  had  never  passed 
urine,  and  whose  bladder  was  enormously  distended,  Middleton 
pushed  a  trocar  through  in  the  direction  of  the  absent  urethra, 
emptied  tlie  l)ladder,  and  kept  tlie  opening  pervious. 

Oberteufer  s  patient,  who  had  atresia  urethra?  and  urachal  fistula, 
relieved  herself  somewhat  by  wearing  a  large  sponge  over  the  um- 
bihcus  secured  in  position  by  a  bandage.  In  such  cases  as  this  the 
apparatus  usually  employed  in  urinary  fistula  should  be  made  use  of. 


MALFORMATIONS    OF    THE    BLADDER. 

These  malformations  follow  the  general  rule  of  being  in  most  in- 
stances due  to  some  defect  in  the  normal  process  of  development. 
Those  which  are  of  sufiicient  importance  and  especially  demand  atten- 
tion are  : 

1.  Fissure. — The  most  frequent  and  prominent  anomaly  of  devel- 
opment in  the  bladder  is  that  of  fissure.  It  consists  in  partial  or 
complete  absence  of  the  anterior  vesical  wall,  and  is  usually  accom- 
panied by  malformations  of  other  organs.  The  anus  and  umbilicus 
in  these  cases,  as  a  rule,  lie  nearer  than  normal  to  the  pubic  symphy- 
sis. 

There  are  various  grades  of  this  affection.  There  may  be  sim- 
ple fissure  of  the  lower  part  of  the  bladder,  with  the  opening  about 
three  quarters  of  an  inch  in  breadth,  as  has  been  seen  by  Desault, 
Palletta,  Gosselin,  Coates,  and  others.  In  the  cases  reported  by 
them  the  symphysis  pubis  was  but  loosely  united.  There  may  also 
be  fissure  of  the  clitoris. 

A  higher  grade  of  this  malformation  is  that  in  which  the  fissure 
is  near  the  umbilicus,  the  lower  part  of  the  pelvic  cavity  and  the 
pubic  symphysis  being  closed,  and  the  lower  part  of  the  bladder, 
urethra,  and  external  genitals  normal.  This  condition  is  next  in 
order  to  patency  of  the  urachus — fistula- vesico-umbili calls.  In  the 
latter  case,  the  urachus  may  remain  pervious  its  entire  length,  and 
open  into  the  ring  of  the  umbilicus. 

The  highest  grade  is  that  in  which  the  whole  anterior  wall  of  the 
bladder  seems  to  be  absent.  In  these  cases  the  inferior  abdominal 
region  is  generally  much  shorter,  and  the  umbilicus  nearer  the  base 
of  the  pelvis.     The  abdominal  walls  ai'e  divided,  and  the  resultant 


628  DISEASES   OF   WOMEN. 

lissure  is  filled  uj)  by  the  bladder-wall,  the  mucous  membrane  of 
which  is  puli'ed  out  and  red,  and  (gradually  merges  into  the  skin  of 
the  abdomen.  It  is  often  wrinkled,  thickened,  moist,  sliiny,  and  the 
edges  dry  and  covered  with  thickened  epidermis. 

On  each  side  of  the  lower  portion  of  the  everted  bladder  are  situ- 
ated the  orifices  of  the  ureters.  They  usually  appear  as  little  ex- 
crescences, but  are  sometimes  hidden  in  the  folds  of  the  membrane. 
The  i^ubic  bones  are  imjierfectly  developed,  and  the  pubic  symphy- 
sis never  closed,  save  by  a  ligamentous  band,  the  bones  lying  from 
half  an  inch  to  three  inches  apart.  These  separations  of  the  pubic 
bones,  as  has  been  shown  by  Dubois,  Duj)uytren,  Mery,  and  Littre, 
are  congenital. 

As  a  rule,  in  such  cases,  the  urethra  is  absent.  The  clitoris  is 
either  divided  A\ath  a  ])ortion  on  each  side  of  the  upper  part  of  the 
imperfectly  formed  labia,  or  there  may  remain  but  a  trace  of  it,  or, 
again,  it  may  be  entirely  absent.  The  hymen  can  be  seen  beneath 
the  fissure.  The  vagina  may  be  absent,  as  in  cases  observed  by 
Herder  and  Eschenbach,  and  the  uterus  may  be  divided  by  a  septum. 
Atresia  vaginae  and  impei-fect  ovaries  have  also  been  found  In  such 
cases.     This  grade  is  known  as  eversio  or  exstropia  vesicae. 

If  there  is  simply  a  fissure  of  the  bladder  the  organ  may  be  pro- 
lapsed through  the  fissure  (inversio  vesicae  cum  prolajjsu  per  fis- 
suram).  This  must  be  distinguished  from  inversio  vesicae  cum  j^ro- 
lapsu  per  urethram  and  exstropia  per  urachum.  That  this  may  be 
clearly  understood,  it  must  be  remembered  that  inversion  of  the 
bladder  occurs  in  three  ways :  First,  by  a  protrusion  of  the  organ 
through  an  opening  or  fissure  in  its  own  walls  (the  form  now  under 
discussion) ;  second,  by  an  inversion  through  the  urethra  ;  and  third, 
by  an  inversion  through  a  pervious  urachus. 

The  ui-eters,  as  a  rule,  are  considerably  widened.  Isenflamm 
found  them  dilated  from  three  quarters  of  an  inch  to  more  tlian  an 
inch ;  Petit  as  much  as  two  inches ;  Flagani  and  Bailie  found  them 
to  be  four  inches ;  Desanlt  three  inches ;  and  Littre  two  and  one 
half  inches,  and  containing  small  calculi.  Their  course,  as  a  rule,  is 
changed,  sinking  deeper  into  the  pelvis,  and  thence  rising  up  into 
the  bladder.  There  are,  however,  exceptions  to  their  enlargement. 
Bonn,  in  one  case,  observed  as  long  ago  as  in  1818,  found  their  length 
and  breadth  normal.  Winckel  also  speaks  of  a  case  where  both  kid- 
neys and  ureters  were  normal. 

The  anomalies  known  as  epi-  and  ana-spadias  belong  under  the 
head  of  vesical  fissures. 

2.  Double  Bladder. — Cases  of  double  bladder,  says  Yoss,  are  be- 


MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA.   629 

coming  quite  rare  as  pathological  knowledge  advances,  for  many 
of  these  were  probably  cases  of  pathological  division  of  the  vaginal 
wall. 

Mollinetti  mentions,  in  his  "  Anatomico-Pathological  Disserta- 
tions," the  case  of  a  woman  with  five  bladders,  live  kidneys,  and  six 
ureters.  Blasius  describes  a  case  of  perfect  division  of  the  bladder 
into  two  separate  halves,  which  at  the  vesical  neck  ended  in  one 
common  urethra.  Each  bladder  had  one  ureter.  The  subject  was  a 
male  adult.  Isaac  Cattier  has  found  this  anomaly  in  little  children. 
One  case  was  that  of  a  child  lifteen  days  old.  The  bladders  were 
separated  by  the  rectum  to  such  a  degree  that  a  finger  could  be  laid 
between  them.  Sommering  found  this  condition  in  a  child  two 
months  old.  In  one  that  was  born  miserably  nourished,  and  lived 
but  twelve  hours,  Schatz  found  perfect  division  of  the  whole  geni- 
tal apparatus,  double  bladder,  and  double  congenital  vesico-vaginal 
fistula.  In  double  bladder,  the  double  allantois,  instead  of  forming 
one  passage,  forms  two,  with  a  ureter  opening  into  each. 

Testa  gives  a  case  of  perfect  separation  by  the  vaginal  wall. 
Scanzoni  found,  in  making  a  post-mortem  examination  on  the  body 
of  a  tuberculous  woman,  a  division  of  the  bladder  into  two  lateral 
halves.  He  does  not  say,  however,  whether  the  division  was  com- 
plete or  whether  the  septum  was  pervious. 

Sometimes  horizontal  septa  are  formed  that  are  due  probably  to 
a  crumphng  up  of  a  part  of  the  bladder  while  growing,  or  a  com- 
mencing closure  of  the  urachus  lower  down  than  usual. 

Koser,  of  Marburg,  had  a  case  of  urachal  cyst,  which,  when 
enormously  distended,  reached  as  far  as  the  umbilicus.  By  means 
of  a  small  connection  with  the  bladder  it  was  filled  when  that  org-an 
contracted,  and,  finally,  it  and  the  bladder  were  emptied  by  contrac- 
tion of  the  abdominal  muscles.  Vesical  cysts  and  diverticula  may 
be  confounded  with  the  anomalies  resulting  from  arrest  of  devel- 
opment. 

The  slightest  grade  of  anomaly  is  that  in  which,  as  Chonsky  has 
observed,  there  is  no  full  septum,  but  simply  a  band  or  seam,  appar- 
ent externally. 

Etiology. — The  original  urinary  sac  of  the  embryo,  it  will  be 
remembered,  is  the  allantois,  which  takes  its  origin  as  a  Gul-de-sao 
from  the  rectum,  and  is,  consequently,  an  offshoot  of  the  intestine. 
It  is  formed  by  the  bagging  of  the  cloaca,  which  bagging  is  due  to 
the  collection  there  of  urine  from  the  primitive  kidneys.  This  allan- 
tois, especially  in  the  human  species,  is  double,  and  remains  only  a 
short  time.     After  the  fourth  week  of  embryonic  life,  the  layei*s 


630  DISEASES  OF  WOMEN. 

coalesce,  and  the  diWsion  ceases.  Yet  the  original  double  form  may 
remain  for  some  time  beyond  the  normal  period,  if  there  are  any 
hindrances  to  union. 

Roose  and  Creve  maintain  that  the  cause  of  this  malformation  is 
the  failure  of  the  pubic  bones  to  unite.  Meckel  takes  exception  to 
this,  and  says  that  the  bladder  in  its  primitive  condition  shows  itself 
as  a  simple,  plain  sm'face,  which  only  becomes  a  cavity  by  the  grow- 
ing toward  each  other  and  union  of  its  edges.  Duncan  and,  at  a 
later  date,  A.  Bonn,  and,  still  later,  B.  S.  Schultze  and  Thiersch, 
held  that  vesical  iissure  had,  as  its  primary  cause,  an  atresia  of  the 
urethra,  with  great  dilatation  of  the  bladder,  the  distended  organ 
pushing  aside,  first,  the  recti  muscles,  later,  the  cartilaginous  pubic 
bones,  and,  finally,  bursting.  E.  Rose,  on  the  contrary,  maintains 
that  these  cases  of  bladder-fissiu-e  are  cases  of  perjDetuated  urachus, 
and  are  due  to  developmental  failure  in  the  bladder  itself,  remain- 
ing open  as  far  as  the  urethra.  He  says  positively  that  the  edges  of 
recent  preparations  of  the  bladder  show  a  fresh,  smooth  surface,  and 
that  there  is  no  trace  whatever  of  any  cicatrix  or  callosity.  He 
mentions  one  case  of  tearing  and  rupture  where  the  evidences  were 
plainly  to  be  seen.  Moergelin,  who  was  unable  to  find  proof  of 
rupture  as  a  cause  of  this  anomaly,  says  that,  if  there  was  a  quan- 
tity of  urine  in  the  bladder,  greatly  distending  it,  there  would  be 
a  reopening  of  the  urachus  or  a  bursting  into  the  abdominal  cavity, 
rather  than  a  rupture  through  the  abdominal  walls.  He  looks  favor- 
ably on  the  idea  of  a  bursting  of  the  allantois  before  the  abdominal 
walls  have  closed  in  front  of  it. 

Against  this,  however,  is  the  fact  that  Hecker  extracted  a  foetus 
with  atresia,  having  an  enormously  dilated,  unruptured  bladder.  He 
found  in  the  abdominal  walls  a  cicatrized  slit  covered  by  perito- 
naeum. This  makes  manifest  the  possibility  of  a  ruptm-e  of  the  ab- 
dominal walls,  and  also  of  the  bladder,  occumng  at  a  comjDaratively 
late  date. 

In  the  case  related  by  Rose  no  information  is  given  as  to  whether 
there  was  a  normal  umbilical  cord  or  not,  whether  there  was  any 
urachal  fistula,  whether  the  abdominal  ring  was  closed  entirely,  or 
whether  the  fissure  was  confined  to  the  inferior  part  of  the  anterior 
vesical  wall,  as  described  by  Gosselin,  Bertet,  and  others.  In  their 
cases  it  was  not  possible  for  the  fissure  to  have  originated  by  the  re- 
opening of  the  urachus.  In  any  event,  most  of  the  late  authors  are 
agreed  that  hindrance  to  the  outflow  of  urine  has  most  to  do  with  the 
production  of  this  anomaly,  and  it  may,  as  Rose  has  shown,  and  as  has 
been  said  before,  arise  from  atresia  or  absolute  absence  of  the  urethra. 


MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA.   631 

Another  possible  mode  of  causation  of  this  malformation  is  by 
the  falling  of  some  of  the  larger  aljdominal  organs  into  the  pelvic 
cavity,  compressing  the  m'ethra,  and  hindering  its  formation.  E. 
Rose  once  found  the  right  kidney  in  the  pelvis,  and  Winckel  has 
recorded  a  case  described  by  one  of  his  students,  Dr.  Kriiger,  where 
the  left  lobe  of  a  considerably  enlarged  liver  and  a  quantity  of  small 
intestines  were  so  tightly  wedged  into  the  pelvis  as  to  cause  marked 
bulging  of  the  perinseum.  Such  a  condition,  coming  at  a  time 
when  the  urachus  and  urethral  end  of  the  bladder  are  firmly  closed, 
must  tend  to  form  a  vesical  fissure. 

Perfect  eversion  of  the  bladder  may,  however,  be  found  at  a  very 
early  date,  even  before  the  two  halves  of  the  allantois  are  joined,  as 
in  cases  related  by  Friedlander,  E.  Rose,  and  Winckel.  Lying  be- 
tween, and  in  front  of  the  single-  or  double-everted  bladder  or  blad- 
ders, there  are  sometimes  found,  as  in  Rose's  and  Winckel's  cases, 
bands  of  perforated  skin-folds,  behind  which  a  sound  may  be  passed. 
Their  presence  may  be  explained  in  this  way :  That  the  underlying 
serous  connective  tissue  (Rathke's  membrana  reuniens  inferior), 
which  closes  the  abdominal  cavity  before  the  development  of  the 
skin  and  muscular  system,  is  the  covering  of  all  urachal  fistulge,  open 
bladders,  and  persistent  allantois.  Then,  where  the  urine  j^ressure 
is  the  greatest,  the  bladders  move  upon  each  other,  so  that  no  further 
development  can  take  place  between  them  ;  but  the  abdominal  plates 
develop  themselves  around  and  between  them. 

This  intermediate  development,  owing  to  the  imperfection  of 
the  lower  connective  tissue,  becomes  a  band  or  rim  where  the  two 
conically  formed  bladders  push  together,  so  that  they  can  not  become 
a  symmetrical  whole,  but  have  an  intermediate  arch.  In  these  cases 
the  cause  probably  lies  in  the  patency  of  the  urachus  and  the  eversion 
of  the  bladder ;  also  the  open  condition  of  the  abdominal  walls,  inter- 
ference with  the  development  of  the  lower  parts  of  the  musculi  recti, 
and,  later,  the  imperfect  development  of  the  pelvis. 

There  can,  however,  be  a  fissure  of  the  abdominal  walls  without 
a  fissure  of  the  bladder,  the  closed  organ  protruding  from  the  ab- 
dominal fissure  (ectopia  vesicae). 

Lately  Ahlfeld  has  brought  forward  the  hypothesis  that  eversion 
of  the  bladder  is  complicated  with  and  dependent  on  a  pulling  down- 
ward of  the  ductus  omphalo-meseraicus,  making  an  obtuse  angle  in- 
feriorly,  whereby,  the  rectum  being  pushed  forward,  it  pushes  the 
inferior  wall  of  the  allantois  before  it.  Communication  between  the 
rectum  and  the  allantois  ceases,  and  the  allantois,  becoming  enor- 
mously distended,  bursts.     Ruge  and  Fleischer  contend  that  in  this 


632  DISEASES  OF   WOMEN. 

affection  the  duct  of  the  umbilical  vesicle  is  implicated,  and  hold 
that  the  tense  cord  (duct)  in  question  is  a  continuation  of  the  uraclius. 

Winekel  is  of  the  opinion  that  burstiniii;  of  the  bladder  at  an 
earlj  stage  from  urine-pressure  is  the  weightiest  cause  in  the  produc- 
tion of  bladder  fissure.  Against  the  idea  of  Hose,  which  is  that 
eversio  vesicie  does  not  take  place  from  rupture,  Winckel  says  that 
the  presence  of  scars  is  not  absolutely  necessary  to  prove  the  point, 
for  the  abdominal  walls  are  not  yet  joined,  and  therefore  can  not  be 
ruptured ;  jmd,  moreover,  he  has  often  seen  children  immediately 
aiter  birth  in  whom  the  umbilical  cord  was  normal,  and  yet  an  ever- 
sion  of  the  bladder  existed.  He  raises  the  query  as  to  why  we  can 
not  have  ruptui-e  of  the  bladder  at  an  early  period,  since  we  know 
that  it  occurs  later  in  life,  as  in  women  with  retroflexion  of  the 
gravid  uterus. 

Another  fact  that  he  advances  in  favor  of  the  view  that  rupture 
of  the  bladder  is  due  to  urethral  obstruction  is  that  it  occurs  oftener 
in  males  than  in  females,  the  former  having  a  canal  mucli  more  favor- 
able to  such  obstruction,  for,  of  sixteen  cases  of  vesico-umbilical  fist- 
ula, given  by  Stadtfeldt,  fourteen  were  males  and  two  females.  Dr. 
Wunder,  of  Altenberg,  in  1831  observed  the  cases  of  two  boys,  aged 
respectively  eight  and  eleven,  with  congenital  e version  of  the  blad- 
der.    It  is  interesting  to  note  that  their  mothers  were  sisters. 

The  various  causes  that  give  rise  to  vesical  fissure  produce  also 
imperfectly  developed  pelvic  bones,  dislocation  of  the  head  of  the 
femur,  and  other  malformations  from  pressure.  The  excessive  dilata- 
tion of  the  bladder  drives  the  horizontal  rami  of  the  pubes  asunder, 
and  the  changed  direction  and  imperfect  growth  of  the  pelvic  bones 
cause  a  lessened  acetabular  circumference  and  consequent  slipping 
out  of  the  head  of  the  femur.  Thus  does  Voss  explain  the  disloca- 
tion occurring  in  one  of  his  cases. 

It  will  be  found  on  touching  the  red  mucous  membrane  of  an 
exposed  bladder  that  it  is  exceedingly  sensitive.  In  such  a  case  the 
urine  may  be  seen  oozing  from  the  uretei'S  and  diibbling  over  the 
surface.  The  mucous  membrane  is  often  protruded  and  wrinkled 
up  by  the  movements  of  the  bowels,  and  can,  in  case  the  bladder- 
opening  is  great,  be  inverted  through  the  fissure  (inversio  vesicae  per 
fissuram)  or  through  the  urachus  (inversio  vesicae  per  urachum).  If 
the  fissure  is  small  it  may  remain  for  years  without  any  inversion. 
If  the  prolapsed  mucous  membrane  is  replaced  and  indirect  pressure 
is  made  on  the  dilated  ureters,  the  urine  will  spurt  from  the  m'eteric 
orifices. 

Sometimes  these  patients  have  partial  control  over  their  urine; 


MALFORMATIONS   OF  THE   BLADDER   AND   URETHRA.      f]83 

as  in  cases  where  an  nrnl)ilical  hernia  exists  witli  umbilical  fissure, 
the  posterior  wall  of  the  bladder  being  forced  into  tlie  opening 
plugs  it  up.  Such  a  case  is  described  by  Paget.  The  hernial  sac, 
which  was  about  the  size  of  a  goose-egg,  completely  plugged  the 
umbilical  foramen  by  pressing  firmly  against  the  posterior  bladder- 
wall.  If  the  patient  desired  to  urinate,  the  contraction  of  the  blad- 
der caused  a  gradual  disappearance  of  the  hernial  tumor ;  and  when 
it  had  entirely  disappeared  he  passed  urine  from  the  umbilicus  and 
then  through  the  urethra.  After  the  urethral  flow  began  the  stream 
from  the  umbilicus  ceased,  and  no  urine  passed  at  that  point  unless 
strong  pressure  was  made  upon  the  abdomen. 

Another  way  in  which  partial  retention  may  be  accomplished  in 
imperfect  eversion  is  by  the  greatly  thickened  muscular  walls  acting 
as  a  sort  of  sphincter.  Such  a  case  given  by  Voss  is  that  of  a  female 
child,  twenty  months  old.  When  lying  down  and  quiet,  the  urine 
did  not  flow  away  so  freely.  The  bladder-wall  was  nearly  one  inch 
in  thickness,  and  the  ureters,  though  three  inches  broad,  were  greatly 
narrowed  at  their  point  of  entrance  into  the  bladder. 

In  fissures  situated  low  down  there  may  be  coincident  inguinal 
hernia,  as  is  illustrated  by  a  case  related  by  Bertet.  This  complica- 
tion may  act  so  as  to  aid  in  the  retention  of  urine.  From  the  con- 
stant flow  of  urine,  the  inferior  end  of  the  fissure  and  neighboring 
parts  become  moist,  red,  eroded,  and  sometimes  incrusted  and  ulcer- 
ated. There  are  various  painful  sensations,  as  itching  and  burning, 
and  the  patient  becomes  a  nuisance  to  herself  and  to  those  about  her 
from  the  offensive  urinous  odor  that  is  constantly  given  off. 

The  edges  of  the  mucous  membrane  in  time  become  changed, 
and  resemble  skin  in  appearance.  At  other  points,  oftentimes,  the 
membrane  is  much  changed,  having  upon  its  surface  loose,  villous 
growths,  that  bleed  readily  when  touched,  and  give  the  impression 
of  a  malignant  new-formation. 

By  reason  of  a  separation  of  the  pelvic  bones  there  is  an  irregu- 
lar, uncertain  gait.  The  pelvic  diametric  proportions,  as  observed 
by  Moergelin,  are  in  these  cases  much  changed,  the  transverse  being 
much  greater  than  the  antero-posterior,  the  dissimilarity  increasing 
as  age  advances,  the  proportion  being  sometimes  trebled.  Women 
with  these  troubles,  however,  have  borne  children. 

A  close  inspection  of  the  ureteric  openings  being  possible  in 
these  cases,  the  interesting  observation  may  be  made  that  in  action 
the  kidneys  seem  quite  independent,  the  one  of  the  other,  the  right 
discharging  urine  and  the  left  none,  or  the  reverse,  or  both  may  dis- 
charge together. 


634  DISEASES  OF   WOMEN. 

Diagnosis. — the  diagnosis  of  iiraclial  listula  is  comparatively 
easy,  for  the  aifection  is  at  once  recognized  by  finding  the  ureteric 
orifices  with  the  m-ine  flowing  from  them. 

As  to  frequency,  the  following  statistics  are  of  importance  : 

In  12,689  new-born  children,  Sickles  found  this  malformation  to 
occur  twice  in  twenty-seven  cases  of  developmental  anomalies. 

In  thirty-five  hundred  ])irths  occurring  in  the  Dresden  Institute, 
from  1872  to  1875,  Winckel  saw  one  case. 

Velpeau,  in  the  year  1 833,  mentions  seeing  and  finding  on  record 
more  than  one  hundred  cases  of  this  kind.  Percy  says  that  he  has 
seen  it  twenty  times  in  his  own  practice.  Winckel  saw  five  cases, 
three  of  which  were  girls,  and  two  boys.  Phillips  saw  twenty-one 
cases,  all  girls ;  but  in  AVood's  twenty  cases,  only  two  were  girls. 

Prognosis. — The  prognosis  is  usually  unfavorable.  The  cliildren 
are  weak  and  puny,  and,  as  a  rule,  die  early.  They  are,  however, 
seldom  destroyed  by  the  fissure  itself.  Many  of  them  are  born  liv- 
ing, and  can  be  kept  alive,  and  some  attain  a  fair  age.  Lebert  saw 
in  Salpetriere  Hospital,  Paris,  an  old  woman  with  this  affection. 
Operative  procedures  and  the  various  apparatus  to  prevent  trick- 
ling of  urine  are  of  little  avail.  This,  however,  is  only  the  case 
in  total  eversion.  Urachal  fistulse,  simple  fistulse,  above  the  pubic 
symphysis,  and  even  those  situated  inferiorly,  where  the  pubic 
bones  are  united,  may  be  readily  cured  by  the  ordinary  operation  for 
fistula. 

Treatment. — Stadtfeldt  operated  in  eight  cases  of  urachal  fistula, 
in  seven  of  which  he  obtained  perfect  heahng.  In  deep  fistula  he 
recommends  freshening  of  the  edges  of  the  skin  and  mucous  mem- 
brane, and  attempting  union  by  the  first  intention.  In  cases  where 
the  edges  extrude  themselves  very  much,  he  puts  on  either  a  clamp 
or  ligature. 

Winckel  favors  operative  procedure  since,  in  that  way,  the  ab- 
normal protrusion  can  be  removed.  Sometimes,  as  recommended  by 
Paget,  it  will  be  sufficient  to  freshen  the  edges,  put  in  insect-pins, 
Hgature,  and  union  may  be  expected  in  from  two  to  four  weeks. 

In  fissura  vesicae,  superior  or  inferior,  an  attempt  might  be  made 
to  draw  the  edges  together,  and  even  to  loosen  the  skin  in  front  by 
incision,  so  as  to  remove  traction  from  the  edges.  In  that  case  it 
will  be  necessary  to  freshen  the  edges  and  put  in  sutures.  The  re- 
sult, unfortunately,  is  not  uniformly  successful. 

In  earlier  times,  in  cases  of  true  eversion  of  the  bladder,  no  one 
dared  to  operate,  and  the  only  alleviation  granted  to  the  patient 
was  such  as  could  be  obtained  by  a  properly-adapted  urinal.     Ku- 


MALFORMATIONS   OF   THE   BLADDER   AND   URETHRA.      635 

merons  appliances  have  been  invented  for  this  purpose,  some  of 
them  very  useful. 

Gerdy  was  the  first  to  operate  for  eversion  by  closure.  Failing 
to  bring  an  inverted  bladder  back  into  place,  he  tried  to  fonn  a  suf- 
ficient sac  by  partial  excision  of  the  ureters.  The  patient,  a  man, 
was  attacked  with  peritonitis  and  nephritis,  and  died. 

Jules  Roux,  in  1853,  proposed  cutting  out  the  ureters,  and  unit- 
ing them  with  the  rectum.  Simon  tried  this  once,  and  succeeded ; 
but  the  patient  died  six  months  after  from  peritonitis  and  exhaus- 
tion. At  a  later  date,  he  again  attempted  to  treat  this  malfoi-ma- 
tion  by  operative  procedures.  He  made  one  inferior  and  two  lateral 
flaps,  but  these  became  gangrenous.  Ten  years  later,  these  attempts 
were  more  successfully  made  by  John  Wood  and  Holmes,  and  their 
results  recorded  by  Podruzski. 

The  first  one,  however,  who  obtained  a  perfect  result  was  Dr. 
Daniel  Ayres,  of  Brooklyn.  He  cut  a  long  flap  from  the  under  and 
lower  side  of  the  abdominal  walls,  turned  the  skin-side  in,  and 
united  it  with  both  edges  of  the  bladder.  A  full  account  of  this 
case  will  be  found  at  the  close  of  this  chapter.  Since  then  I  have 
seen  three  cases,  but  as  they  were  not  patients  of  mine  I  had  no 
opportunity  to  interfere  surgically  in  their  treatment. 

Subsequently,  Wood  operated  on  a  girl  one  year  and  a  half  old, 
whose  bladder-fissure  was  continuous  with  the  uro-genital  sinus,  so 
that  the  os  and  cervix  uteri  were  always  wet.  He  raised  one  flap 
from  the  neighborhood  of  the  umbilicus,  and  another  from  the 
soft  parts,  and  turning  the  skin-side  in,  covered  them  with  a  larger 
flap  from  the  other  side.  The  mucous  membrane,  however,  pushed 
through  inferiorly,  and  broke  the  fresh  adhesions. 

Ashhurst's  case  was  more  successful.  He  cut  a  piece  from 
under  the  umbilicus,  and  joined  it  with  two  flaps  from  the  sides 
(they  being  somewhat  turned)  so  that  their  upper  edges  met  each 
other  in  the  median  line.  They  were  joined  by  sutures,  and  through 
each  side  of  the  upper  flaps  two  pieces  of  malleable  iron-wire  were 
carried,  then  drawn  through  the  lateral  flaps,  and  twisted  over  little 
rolls  of  plaster.  Ti-action  was  thus  relieved.  The  flaps  healed  by 
the  first  intention.  The  sutures  were  removed  on  the  eighth  day. 
The  rest  of  the  wound  healed  by  granulation.  When  in  the  up- 
right position,  incontinence  of  urine  still  continued  ;  but  when  lying 
upon  her  back,  the  patient  was  able  to  retain  urine  for  about  two 
hours,  her  general  condition  being  thus  greatly  improved. 

Ashhurst  gives  a  resume  of  twenty  cases  of  eversio  vesicae,  oper- 
ated on  up  to  his  time.     Fourteen  of  these  were  successful — Ayres, 


636  DISEASES   OF  WOMEN. 

Holmes,  "Wood,  Morey,  and  Barker,  each  being  credited  witli  one. 
Three  were  unsuccessful,  by  Holmes  and  Wood ;  and  three  resulted 
fatally,  by  Richard,  Pancoast,  and  Wood.  In  the  last  two  death 
resulted  from  causes  other  than  the  operation. 

In  all  cases  when  the  skin  is  turned  in,  the  growth  of  hair  al- 
ready present  or  to  come  will  be  apt  to  give  rise  to  incrustations. 
Thiersch,  in  his  six  cases,  allowed  the  flaps  to  granulate  on  their  raw 
surface  before  applying  them.  When  the  flap-union  is  perfect,  he 
advises  closing  completely  the  upper  part  of  the  bladder. 

The  diagnosis  of  double  bladder  may  be  made  by  urethral  dilata- 
tion and  exploration  by  the  finger  and  catheter. 

Destruction  of  the  bladder-sej^ta  is  not  to  be  thought  of.  In  case 
of  the  existence  of  urachal  cyst  causing  difficult  urination,  one  might 
try  extirpation  of  the  cyst  by  cutting  into  the  abdominal  walls,  and 
after  freshening  their  edges  unite  them  with  those  of  the  bladder. 

ILLUSTKATIVE    CASES. 

Extroversion  of  the  Urinary  Bladder.  (By  Daniel  Ayres,  M,  D., 
LL.  D.) — The  patient  was  admitted  to  the  Long  Island  College  Hos- 
pital, ]S"ovember  1,  1858,  and  a  history  of  the  case  recorded  by  the 
house  surgeon,  Dr.  Ostrander. 

She  is  twenty-eight  years  of  age,  born  of  healthy  parents,  both 
of  whom  were  free  from  deformity ;  her  height  is  below  the  aver- 
age of  females,  and  she  is  unmarried.  She  declares  her  health  to 
have  been  always  good,  appetite  and  digestion  excellent,  bowels 
regular,  and  the  catamenia  in  all  respects  normal. 

She  states  that,  on  the  5th  of  July  preceding,  she  was  delivered 
of  a  well-developed  child,  having  carried  it  to  maturity  without 
extraordinary  difficulty.  Labor  commenced  with  free  haemorrhage 
(footling  f»resentation),  and  lasted  two  hours,  at  the  end  of  which 
time  the  child  was  born,  having  died  in  process  of  delivery.  Peri- 
nseura  uninjured.  She  reports  having  made  a  tolerable  recovery, 
though  for  a  long  time  weak,  and  her  present  appearance  is  some- 
what anaemic. 

Shortly  after  she  began  walking  about  symptoms  of  prolapsus 
uteri  came  on,  becoming  gradually  worse,  until  the  organ  projected 
external  to  the  vulva,  attended  with  dorsal,  dragging  pain,  difficulty 
of  locomotion,  and  gastric  disturbance. 

In  quest  of  relief,  she  entered  the  Brooklyn  City  Hospital  on 
the  1st  of  September  following  her  confinement,  and  remained  there 
one  month.  Here  she  states  that  a  variety  of  pessaries  were  tried, 
none  of  which  could  be  retained,  and  finally  a  surgical  operation 


MALFORMATIONS  OF  THE   BLADDER  AND   URETHRA.      G37 

was  performed,  tlic  nature  and  character  of  which  is  not  very  appar- 
ent. A  short  article,  descriptive  of  this  case,  appeared  in  the  "  Vir- 
ginia Medical  Journal"  for  January,  1859,  written  by  the  house 
surgeon  of  that  institution.  Tlie  writer  states  tliat  an  attempt  was 
made  to  retain  the  prolapsed  uterus  "  by  removing  an  inch  of  mu- 
cous membrane  from  the  bottom  and  sides  of  the  vulva,  and  unit- 
ing them  by  two  ligure-of-eight  sutures,  which  were  removed  on 
the  sixth  day,  when  no  adhesion  was  found  to  have  taken  place." 
Tlie  writer  continues :  "  The  patient  was  allowed  to  get  up  on  the 
fourteenth  day,  when  the  prolapsus  was  found  to  exist  nearly  as 
much  as  before,"  etc. 

It  is  obvious  that  no  effort  was  made  to  relieve  the  congenital 
deformity,  and  that  she  was  discharged  in  much  the  same  condition 
as  when  she  entered. 

Finally,  a  species  of  stem-pessary  was  contrived  which  was  in- 
tended to  support  the  uterus,  while  kejDt  in  position  by  strings 
passed  around  the  thighs.  This,  however,  proved  very  inefficient — 
the  uterus  slipping  by  the  instrument  upon  the  slightest  extra  exer- 
tion. Moreover,  the  parts  had  now  assumed  an  irritable  condition, 
partly  due  to  increased  friction  of  the  apparatus,  and  undue  attention 
to  cleanliness,  added  to  the  causes  already  noted  ;  altogether,  her  de- 
plorable condition  was  scarcely  susceptible  of  being  made  worse. 

I  may  here  remark  that  the  figures,  both  before  and  after  the 
operation,  have  been  photographed  from  accurate  plaster- casts,  taken 
directly  from  the  patient — a  very  difficult  and  delicate  procedure, 
for  which  I  am  much  indebted  to  the  skill  and  kindness  of  my 
colleague  Dr.  Bauer,  and  our  valuable  assistant,  Mr.  J.  F.  Esslinger. 

Fig.  221  is  an  exact  representation  of  the  parts  at  the  time  of 
presentation  to  the  clinical  class  of  the  Long  Island  College  Hospi- 
tal, for  the  purpose  of  critical  examination.  The  prolapsus,  having 
been  carefully  and  completely  reduced,  was  found  to  retain  its  place 
so  long  as  the  patient  maintained  the  recumbent  position. 

The  distance  between  j3ubic  abutments  was  estimated  at  about 
three  inches. 

The  bladder  (a)  formed  an  oval,  elliptical  tumor,  mammillated 
upon  the  surface,  which  in  the  recumbent  position  measured  two 
inches  in  its  long,  and  one  inch  and  a  quarter  in  its  short  diame- 
ter. This  was  soft,  elastic,  or  bright  vermilion  color,  and  covered 
with  a  thick  tenacious  mucus ;  bleeding  readily  when  rudely  han- 
dled, and  so  exquisitely  sensitive,  that  while  under  the  full  influence 
of  chloroform,  and  insensible  to  the  knife,  a  sponge  passed  over  the 
exposed  bladder  excited  reflex  motions. 


638 


DISEASES  OF  WOMEN. 


The  integument  immediately  surrounding  tlie  bladder  was  found 
red  and  puckered,  but  very  soft,  delicate,  and  free  from  liair  be- 
tween the  bladder  and  point  of  sternum.     The  labia  majora  {o,  o,) 

thick,  fleshy,  and  luxuri- 
antly covered  with  hair, 
were  gathered  into  folds 
swelling  away  toward 
either  thigh  ;  these  were 
carefully  shaved  previous 
to  taking  the  cast  and  per- 
forming tlie  operation. 

The  nymph?e  occu- 
pied isolated  positions 
on  each  side  of  the  vul- 
va, and  are  designated  in 
all  the  figures  by  the  let- 
ters h,  Ij. 

Between    these    and 
the  vagina  Ijelow  no  trace 
of  clitoris  or  urethra  could 
be  distinguished,  but  the 
J-  whole   surface  was  cov- 

Biadder  ^red  witli  mucous  mem- 
exposed,  forming  a  bright  vermilion  tumor;  6,6,  braue,  COntinuOUS  with 
labia  minora ;  o,  o,  above  labia  majora ;  c,  vagina ;      -.  .      •■  ■, .    . 

c/,  anus.  tne  vaginal  lining. 

Here,  then,  we  had 
to  contend  with  two  formidable  difficulties,  either  of  which  was  a 
problem  in  itself,  viz.,  aggravated  prolapsus  from  an  entire  ab- 
sence of  an  anterior  support,  added  to  the  original  congenital  mal- 
formation. 

To  fonn  an  estimate  of  the  value  attached  to  surgical  operations 
in  these  cases,  we  can  not  do  better  than  quote  the  opinion  of  Prof. 
Erichsen,  of  University  College,  London.  Having  collected  the 
experience  of  the  profession  on  this  topic,  his  eminent  position  at 
the  center  of  surgical  science,  added  to  his  well-knoAvn  and  exten- 
sively recognized  erudition,  renders  him  at  once  a  i-eliable  and  com- 
pendious authority  on  the  subject. 

"  This  malformation,"  says  he,  "  is  incurable.  Operations  have 
been  planned,  and  performed  with  a  view  of  closing  in  the  exposed 
bladder  by  plastic  procedures,  but  they  have  never  proved  success- 
ful, and  have  terminated  in  some  instances  in  the  patient's  death ; 
they  do  not,  therefore,  afford  much  encouragement  for  repetition.-' 


Fig.  221. — Extroversion  of  the  bladder. 


MALFORMATIONS  OF  THE   BLADDER  AND  URETHRA.      639 


So  unsatisfactory  have  been  the  results  of  these  operations  that 
the  profession  lias  not  been  favored  with  their  general  plan,  their 
details,  nor  the  causes  of 
failure.  It  must  be  evi- 
dent, however,  that  op- 
erations based  upon  the 
principles  of  plastic  sur- 
gery alone  offer  pros- 
pects of  success. 

The  most  probable 
source  of  failure,  and 
one  which  challenged 
our  early  attention,  was 
the  disastrous  result  to 
be  apprehended  irom 
urinary  infiltration, 

which,  by  its  irritating 
character,  would  neces- 
sarily destroy  all  pros- 
pect of  union,  if  it  did 
not  induce  extensive 
sloughing  of  the  abdom- 
inal parietes ;  peritonitis 
and    purulent    phlebitis 

are  likewise  probable  sources  of  danger,  unless  carefully  guarded 
against.  Indeed,  these  may  all  become  inevitable  consequences  of 
attempting  to  accomplish  too  much  at  one  time ;  and  it  was  there- 
fore determined  to  arrange  our  proceedings  with  a  special  ^^ew,  if 
possible,  to  avoid  them.  The  indications  which  it  was  proposed  to 
follow  were : 

1.  To  form  an  anterior  wall  for  the  exposed  bladder, 

2.  To  restore  the  urinary  canal. 

3.  To  establish  the  anterior  fourchette  of  the  vulva. 

4.  To  supply  means  to  prevent  the  prolapsus,  and  to  collect  the 
renal  secretions. 

The  delicate  character  of  the  integument  above  the  bladder  and 
its  well-known  transmutability  into  the  conditions  of  a  mucous  mem- 
brane peculiarly  adapted  it  to  supply  the  anterior  cystic  wall,  and 
thus  fulfill  the  primary  indication. 

With  these  objects  in  view,  the  operative  proceedings  were  di- 
vided into  two  stages. 

The  first  consisted  in  raising  a  flap  from  the  anterior  portion  of 


Fig.  222. — e,  Linear  cicatrix,  formed  by  the  flaps  cov- 
ering the  bladder ;  b,  b,  nj'mphcE  brought  together, 
and  inclosed  by  the  vulva. 


640 


DISEASES   OF    WOME.NT. 


the  abdomen,  including  the  superficial  fascia,  turning  its  cuticular 
surface  down  over  the  exposed  bladder  as  far  as  its  inferior  border, 
and  securing  the  lateral  union  of  the  Hap  in  that  position,  while  a 
free  exit  below  was  maintained  for  the  urinary  discharge ;  an  im- 
portant result,  still  further  assisted  by  the  dependent  situation  of 
the  outlet  of  the  ureters  already  alluded  to. 

By  these  means  it  was  proposed  to  accustom  the  highly  sensitive 
bladder  to  a  gradual  and  methodical  compression  while  the  flap  it- 
self was  insured  ample  space  to  undergo  such  swelling  as  might  be 
anticipated  from  its  new  position  and  the  unusual  stinmlation  of  a 
new  secretion.  Time  was  likewise  given  for  the  necessary  trans- 
mutation of  tissues  to  make  some  progress. 

The  steps  of  this  procedure  will  perhaps  be  better  understood 

by  a  more  detailed  state- 
ment of  the  "first  operation, 
in  connection  with  the  di- 
agrammatic plates.  Figs. 
223  and  224. 

It  was  performed  on 
the  16th  of  November  last, 
the  patient  being  thor- 
oughly under  the  influ- 
ence of  chloroform,  and  a 
sugar  -  loaf  -  shaped  flap 
having  been  previously 
marked  out  upon  the  ab- 
dominal integument  ;  its 
base,  E,  F,  three  inches  in 
width,  was  situated  three 
fourths  of  an  inch  above 
the  cystic  tumor,  and  ex- 
tended tive  inches  in 
length,  with  its  apex  to- 
ward  the   ensiform    cai'ti- 


FiG.  223. — A,  Bladder,  covered  by  deep  flaps ;  d,  b, 
nymphie ;  c,  vagina  ;  d,  anus. 


lage.     The  dark  line  E,  H,  G,  I,  F  (Fig.  223),  indicates  its  form, 
position,  and  the  line  of  incision. 

This  flap  being  left  snfliciently  large  to  meet  the  elevated  form 
of  the  bladder  and  allow  for  shrinkage,  was  quickly  but  carefully 
separated  from  its  cellular  attachments,  down  to  the  line  E,  F, 
while  two  lateral  incisions,  E,  J,  and  F,  K,  were  continued  directly 
downward  and  toward  the  nymphge,  to  serve  as  beds  for  receiving 
the  sides  of  the  new  flap. 


MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA.   041 


The  iutegmiients  covering  the  hiteral  and  inferior  portions  of  the 
abdomen,  extending  from  G  to  J  on  one  side,  and  from  G  to  K  on 
the  other,  were  now  sufficiently  separated  from  their  cellular  attach- 
ments to  the  muscles  beneath  to  insure  their  sliding  freely,  and  meet- 
ing without  tension  at  the  mesial  line,  G,  N  (Fig.  224).  When 
brought  into  this  position  they  completely  covered  from  view  the 
raw  surface  of  the  Hap  already  turned  over,  and  investing  the  blad- 
der, with  the  exception 
of  a  triangular  space, 
J,  N,  K  (Fig!  224),  f  onned 
by  the  coaptation  of  the 
lateral  flaps  ;  this  was 
temporarily  covered  by 
reflecting  back  upon  it- 
self the  corresponding  tri- 
angular free  end  of  the 
deep  flap,  J,  C,  K  (Fig. 
224),  and  attaching  it 
along  the  line,  J,  N,  K. 
Numerous  points  of  in- 
terrupted suture  were 
used  to  I'etain  the  parts 
in  situ^  assisted  by  long 
strips  of  adhesive  plaster, 
compresses,  and  a  reten- 
tive bandage  around  the 
body.  It  will  be  observed 
that  the  lower  portion  of 

the  cystic  tumor  was  thus  temporarily  left  free  and  partially  ex- 
posed, while  no  portion  of  cut  or  denuded  surface  remained  uncov- 
ered. 

The  patient  received  a  large  dose  of  opium,  and  was  strictly 
maintained  in  the  recumbent  position  upon  a  bed,  properly  pro- 
tected; such  additional  measures  being  adopted  as  would  secure 
cleanliness. 

As  the  parts  subjected  to  operation  began  to  swell,  she  com- 
plained of  irritation  and  pressure  upon  the  bladder,  which,  however, 
were  promptly  met  with  morphine  alone,  and  subsided  in  the  course 
of  a  few  days.  Now  was  exhibited  the  great  importance  of  leaving 
the  tumor  partially  uncovered,  while  all  the  cut  surfaces  were  in 
close  contact,  and  thus  freed  from  the  action  of  irritating  secretions ; 
important  facts  duly  dwelt  upon  and  recently  enforced  with  great 
42 


Fig.   224. — a,  Bladder ;  b,  b,  nymphae  ;  c,  vagina ;  d, 
anus. 


642  DISEASES  OF  WOMEN. 

stress  by  the  distinguished  Prof.  Syme,  of  Edinbiiro;h,  whose  con- 
tributions to  the  surgical  treatment  of  the  urinary  organs  have  alone 
placed  both  hemispheres  under  permanent  obligation  to  him. 

On  the  fourth  day  after  tlie  operation  all  sutures  were  removed, 
the  wounds  having  healed  by  first  intention  or  primary  adhesion, 
with  the  exception  of  a  spot  the  size  of  a  ten-cent  piece,  situated 
just  above  the  point  of  the  triangle,  and  where  the  deep  tiup  had 
been  reflected  over  the  bladder.  At  this  point  the  lateral  abdominal 
flaps  were  necessarily  raised  up  from  the  tissues  beneath,  and  could 
not  be  brought  into  contact  even  by  the  use  of  compresses.  This, 
however,  granulated  kindly,  and  was  nearly  cicatrized  on  the  Tth  of 
December,  when  the  second  and  last  operation  was  performed,  as 
follows : 

The  patient  being  under  the  influence  of  chloroform  the  lower 
triangular  flap,  J,  N,  K  (Fig.  224),  was  dissected  from  its  recent  and 
temporary  attachments,  both  lateral  and  deep,  and  turned  down  over 
the  vulva  as  indicated  by  the  dotted  line,  J,  C,  K. 

Two  incisions,  J,  L,  and  K,  M,  were  now  carried  from  the  ex- 
ternal angles  of  this  triangle,  perpendicularly  toward  and  terminat- 
ing just  behind  the  nymphse,  B,  B. 

The  lateral  flaps  bounded  by  the  lines  N",  J,  L,  and  N,  K,  M, 
and  including  the  labia  majora,  were  then  freely  dissected  from  over 
the  abutments  of  the  pubic  bones  until  they  could  be  readily  slid  to 
meet  each  other  at  the  central  line,  'N,  C,  which,  being  a  continua- 
tion of  the  line  G,  N,  reduced  the  whole  to  a  single  linear  wound, 
occupying  the  "  linea  alba."     (See  Fig.  222.) 

During  the  operation  several  arterial  branches  bled  freely,  and 
were  arrested  by  torsion  and  the  free  application  of  ice,  after 
which  the  flaps  were  confined  at  the  mesial  line  by  points  of  inter- 
rupted suture,  the  most  inferior  one,  viz.,  at  L,  and  M,  being  made 
to  include  the  apex  C,  of  the  triangular  flap. 

Fearing  to  depend  on  sutures  alone  to  secure  the  approximated 
flaps,  and  the  use  of  adhesive  plaster  being  excluded  by  the  irregu- 
larity and  jDOsition  of  the  parts,  the  whole  surface  between  the  jjoints 
of  suture  was  hermetically  incased  by  strips  of  patent  lint,  soaked 
in  collodion  and  accurately  applied.  In  addition  to  this,  pieces  of 
muslin  were  by  the  same  method  firmly  attached  to  the  labia  majora, 
at  some  distance  from  the  mesial  line,  and  to  these  sutures  silk  was 
fastened  in  such  manner  as  to  form  a  lacing  across  and  over  the 
wound.  By  means  of  this  dressing  all  tension  was  removed  from 
the  sutures,  urine  was  totally  excluded,  while  rapid  and  perfect  ad- 
hesion soon  followed. 


MALFORMATIONS   OF  THE   BLADDER  AND   CRETHRA.      643 

Thus  a  urinary  canal  was  formed  which  would  admit  the  little 
finger  to  be  passed  up  one  inch  and  a  half.  The  anterior  four- 
chette  of  the  vulva  was  firmly  established,  and  the  mons  veneris  as- 
sumed its  prominent  and  natural  appearance. 

The  last  cast  of  the  parts  representing  her  present  condition 
(Fig.  222)  was  taken  on  the  4tli  of  January,  1859,  previous  to  which 
time,  the  parts  being  all  firmly  united,  she  was  permitted  freely  to 
walk  about,  and  left  the  hospital  to  spend  the  holidays  with  her 
friends.  No  artificial  support  whatever  was  applied,  in  order  to  as- 
certain how  far  the  operation  would  succeed  in  preventing  the  pro- 
lapsus. 

After  a  severe  test,  the  anterior  fold  of  the  vagina  alone  de- 
scended, and  that  for  a  short  distance,  forming  a  pale,  oedematous 
tumor,  occupying  the  vulva,  about  the  size  of  an  English  walnut. 
The  anterior  fourchette  of  the  vulva  remaining  firm  and  resisting,  a 
light,  oval  pessary,  made  of  vulcanized  rubber,  and  perforated,  was 
introduced  into  the  vagina  and  readily  retained  in  situ.  After  thor- 
ough trial,  this  was  found  to  support  the  parts  completely,  and  with- 
out the  slightest  uneasiness,  even  under  active  exertion  and  straining. 

This  was  a  better  result  than  had  been  anticipated,  inasmuch  as 
it  was  intended  to  rely  mainly  upon  a  disk-shaped  pessary,  sup- 
ported by  a  foot  attached  to  a  simple  apparatus  which  we  had  con- 
structed to  act  as  a  reservoir  for  the  urine. 

January  20,  1859.  The  patient  was  again  examined  at  the  hos- 
pital, in  the  presence  of  a  number  of  medical  gentlemen,  she  having 
walked  a  distance  of  two  miles  without  experiencing  any  incon- 
venience. The  parts  were  all  found  sound  and  firm,  and  her  gen- 
eral health  and  spirits  much  improved. 

Patent  Urachus  with  Calculus.  (H.  D.  Yosburgh,  M.  D.,  "  New 
York  Medical  Record,"  September  22,  1877.) — Several  months  ago 
I  was  called  to  see  J.  H,  B.,  fifty,  a  mechanic,  of  spare  habit,  and 
always  in  good  health.  He  complained  of  soreness  and  constant 
pain  at  the  umbilicus,  and  on  examination  I  found  the  natural  de- 
pression filled  up  by  a  rounded  tumor,  apparently  the  natural  tissue 
enlarged  by  swelling.  There  was  also  circumscribed  hardness  of  the 
tissues  around  the  umbilicus.  The  parts  were  red  and  very  tender 
to  the  touch,  having  every  appearance  of  an  ordinary  erysipelas. 

At  the  time  of  my  visit  he  told  me  that  a  score  or  more  of  years 
before,  after  a  similar  experience,  his  attending  physician  at  that 
time  removed  a  "  stone  "  from  the  umbilicus.  I  applied  a  poultice, 
and  awaited  developments.  The  above  condition  continued  from 
day  to  day,  with  the  exception  that  the  tumor  projected  more  and 


044  DISEASES  OF  WOMEN. 

more  from  tlie  umbilicus,  and  the  circumscribed  hardness  decreased. 
Any  movement  of  the  body  or  handling  of  the  tumor  produced  se- 
vere cuttin*)^  pain  in  the  part,  The  tniiior  was  exquisitely  tender. 
No  constitutional  symptoms  accompanied  the;  tn^uble. 

On  the  tenth  day  from  my  first  visit  1  niade  an  incision  into  the 
tumor  for  the  purpose  of  cx^jloration,  about  half  an  inch  in  depth, 
when  I  came  upon  a  hard  substance  wliich,  after  consi(leral>le  ditH- 
culty,  I  removed,  and  found  to  be  a  concretion,  smooth  and  ovoid 
in  8haj)e,  about  the  size  of  a  medium  liickory-nut,  and  of  the  color 
and  appearance  of  a  phosphatic  calculus,  with  a  strong  urinous 
smell.  After  the  removal  the  wound  readily  healed.  The  ordinary 
retraction  of  the  tissues  within  the  navel  fossa  took  place,  and  the 
man  has  sulfered  no  inconvenience  since. 

What  was  the  concretion  ?  In  the  "  Medical  Record,"  No.  354, 
Dr.  Rose's  article  describing  a  patent  urachns  called  this  case  to 
mind,  and  I  have  transcribed  the  above  from  my  notes  of  the  time. 

I  can  not  conceive  this  concretion  to  have  been  anything  else 
than  a  calculus  formed  from  urinary  deposit  in  a  patent  urachns. 

No  treatise  within  my  reach  mentions  anything  of  the  kind,  and 
the  novelty  of  the  case  is  my  reason  for  reporting  it. 

In  this  man  there  was  doubtless  a  similar  calculus  formation 
something  more  than  twenty  years  before. 

Very  Rare  Form  of  Monstrosity  of  the  Female  Genito-Urinary  Or- 
gans ("  Gazette  des  Ilopitaux.") — In  the  words  of  M.  Tillaux,  at  the 
Hospital  Lariboisiere,  there  is  at  present  a  small,  deformed  woman, 
twenty-six  years  of  age,  who  presents  an  exstrophy  of  the  bladder, 
with  complete  absence  of  the  vagina.  The  external  organs  of  gen- 
eration are  represented  only  by  the  orifice  of  the  uterus,  which  is 
situated  in  the  median  line  almost  on  a  level  with  the  skin,  and  by 
rudimentary  labia  minora  and  majora  which  are  not  united  in  front. 
The  clitoris,  urethra,  and  anterior  wall  of  the  bladder  are  absent. 
The  ureters  open  into  the  rudimentary  bladder  near  the  median  line. 
Palpation  shows  that  the  pubic  bones  are  separated  in  front  by  a 
space  that  is  about  as  wide  as  five  fingers,  and  the  pelvis  seems  to 
be  enlarged  to  that  extent.  The  umbilical  cicatrix  is  located  at  the 
middle  of  the  superior  border  of  the  exstrophic  bladder.  The  cei-vix 
uteri  forms  a  slight  prominence  into  which  the  skin  is  attached.  It 
is  conical  in  form.  The  cavity  of  the  uterus  is  of  nearly  the  normal 
depth,  but  rectal  examination  shows  that  in  shajjc  the  organ  retains 
the  peculiarities  of  childhood.  The  patient  began  to  menstruate  at 
the  age  of  fifteen  3'ears,  and  since  then  has  been  perfectly  regular. 

Operative  Treatment  of  Ectopia  Vesicse.     (By  Prof.  Trendelen- 


MALFORMATIONS  OF  THE  BLADDER  AND  URETHRA.   645 

burg,  Bonn ;  "  Centbl.  f .  Chirg.,"  18S5,  No.  49.)— Former  methods 
are  criticised.  Thiersch's  fiap-closure,  e.  g.,  does  not  secure  use  of 
the  bladder  musculature.  Trendelenburg's  first  attempts  to  secure 
direct  union  of  a  vesical  and  urethral  iisssure  by  joining  its  lateral 
edges  were  begun  live  years  ago.  His  plan  is  by  dividing  the  sacro- 
iliac synchrondrosis  on  each  side  to  mobilize  the  iliac-  flanges,  and 
then  by  lateral  pressure  to  approximate  them  in  front.  Finally,  the 
fissure  thus  narrowed  is,  after  reposition  of  the  bladder  to  be  directly 
closed  by  freshening  and  suturing  its  edges.  Inferiorily  the  union 
is  to  be  continued  at  least  to  the  beginning  of  the  pars  bulbosa  ure- 
thrne.  Division  of  the  sacro-iHac  symphysis  is  in  children  simple, 
and,  when  carefully  done,  not  dangerous.  The  child  is  laid  on  its 
belly,  and  a  finger  introduced  into  the  rectum  to  determine  the  po- 
sition of  the  incisura  ischiadica  major  and  superior  gluteal  artery. 
A  long  cut  is  then  made  over  said  symphysis  ;  this  is  gradually  deep- 
ened until  strong  lateral  pressure  makes  the  pelvic  flange  yield.  On 
account  of  the  large  pelvic  vessels  it  is  not  permissible  to  cut  through 
the  deepest  portion  of  the  symphysis.  Toward  puberty  and  later  in 
'  life  this  operation  would  have  to  be  done  with  the  chisel,  and  would 
be  more  serious.  The  construction  of  a  continuously  active  com- 
pressing apparatus  that  could  be  tolerated  for  weeks  proved  diffi- 
cult. Tourniquet  arrangements  were  not  borne.  A  girdle  crossing 
in  front,  with  extension  weights  of  ten  to  fifteen  pounds  attached, 
has  of  late  proved  satisfactory.  Where  previously  the  spinse  sup. 
ant.  were  seventeen  centimetres  apart,  they  approached  to  within 
eleven  and  a  half  centimetres.  The  two  pubic  symphysis  stumps, 
formerly  two  inches  apart,  were  now  almost  in  contact.  It  is  well 
to  delay  the  operation  for  the  fissure  some  six  or  eight  weeks.  This 
second  operation  begins  with  freshening  the  fissure  borders  ;  he  then 
frees  the  edges  of  the  bladder  somewhat,  and  unites  with  Lem- 
bert's  sutures.  The  urethra  has  usually  been  included  in  the  oper- 
ation. A  catheter  is  left  for  a  few  days.  In  all  cases  as  yet  the 
union  to  the  extent  of  urethra  and  bladder-neck  has  subsequently 
separated.  In  a  two  and  a  half  year  old  boy  the  remainder  of  the 
bladder  held  and  the  prolapse  was  remedied.  He  thinks  that  by 
further  perfecting  his  operation  it  may  prove  successful. 

Operation  for  Congenital  Extroversion  of  the  Bladder  of  an  Infant 
Five  Days  old.— (By  H.  C.  Wyman,  M.  D.,  Detroit,  Michigan, ''  Xew 
York  Medical  Record,"  December  12,  1885). — From  the  umbilicus 
down  to  the  triangular  ligament  there  was  a  failure  of  development 
causing  an  extroversion  of  the  posterior  wall  of  the  bladder,  show- 
ing the  orifices  of  the  ureters  and  an  absence  of  the  dorsum  of  the 


e4:6  DISEASES  OF  WOMEN. 

penis.  Dribbling  of  urine  from  the  ureters  was  constant.  Under 
cliloroform  incisions  were  made  on  either  side  through  the  integu- 
ment and  superiicial  fascia  just  forward  of  the  anterior  superior 
spine  of  the  ilium  two  inches  upward,  to  secure  relaxation ;  the 
edges  of  the  Ussure  were  then  pared  and  fastened  together  Avith 
harelip  pins  with  intermediate  sutures,  and  the  wound  dressed  with 
oxide  of  zinc  and  absorbent  cotton,  a  drainage-tube  for  the  urine  be- 
ing left  in  the  wound.  The  penis  was  not  touched,  being  reserved 
for  a  secondary  operation.  The  recovery  was  rapid  and  perfect. 
The  child  died  from  convulsions  two  months  later,  before  the  opera- 
tion upon  the  penis  could  be  performed. 


CHAPTER  XXXVI. 

FUNCTION    OF    THE    BLADDER. 

The  function  of  tlie  bladder  is  to  act  as  a  reservoir  for  the  urine, 
and  at  proper  intervals  to  expel  it  through  the  urethra.  The  tilling 
of  the  organ  with  urine  is  a  comparatively  slow  and  gradual  process, 
the  fluid  entering  it  from  the  ureters  drop  by  drop,  or  in  a  very 
small  stream.  As  it  enlarges  it  does  so  in  the  direction  of  least  re- 
sistance, viz.,  laterally  and  superiorly.  The  lateral  being  its  long- 
est diameter,  it  enlarges  first  in  that  direction,  until  after  a  time  a 
limit  is  set  by  the  bony  pelvic  boundaries,  when  it  rises  from  the 
pelvis  somewhat,  thus  escaping  from  the  pressure  below.  This 
movement  of  the  bladder  is  facihtated  by  its  serous  surface  gliding 
easily  over  that  of  the  adjacent  organs. 

The  bladder  receives  its  nervous  supply  partly  from  the  mesen- 
teric ganglia  of  the  sympathetic,  and  partly  from  the  lumbar  portion 
of  the  spinal  cord  :  it  has  therefore  nerve-filaments  from  both  the 
cerebro-spinal  and  sympathetic  systems.  The  sphincter  vesicae  is  in 
health  in  a  state  of  tonic  contraction  which  results  in  retaining  the 
urine  in  the  bladder.  This  act  is  entirely  involuntary  and  uncon- 
scious and  is  performed  in  a  perfect  manner  both  during  the  waking 
and  sleeping  hours.  When  it  is  desired  to  evacuate  the  bladder  this 
sphincter  is  relaxed  by  an  act  of  the  will  conveyed  through  the 
cerebro-spinal  fibers,  but  this  relaxation  once  accomplished,  the 
further  act  by  which  the  organ  is  emptied  is  performed  without  the 
intervention  of  the  will.  The  experiments  of  Kupressow  demon- 
strate conclusively  that  the  nervous  center  which  presides  over  con- 
traction and  relaxation  of  the  sphincter  vesicae  is  located  in  the  lum- 
bar region  of  the  spinal  cord.  And  it  may  be  accepted  that  with 
other  functions  of  a  protective  nature  the  spinal  cord  maintains  the 
normal  action  of  the  urinary  organ. 

There  has  been  considerable  discussion  among  different  authors 
as  to  whether  closure  of  the  vesical  urethral  orifice  is  a  voluntaiy  or 


648  DISEASES  OF  WOMEN. 

an  involuntary  act.  Witte  and  Rosenthal  maintain  that  the  closure 
is  due  to  "  tonicity  from  nerve  force,"  whicli  resists  tlie  urine  press- 
ure. Kuprossovv  holds  the  same  view,  bu.sing  his  opinion  on  a  se- 
ries of  experiments  which  he  made,  and  further  maintains  that  the 
sphincter  vesicae  is  at  the  neck  of  the  bladder  to  eject  the  urine 
completely  out  of  the  urethra,  in  place  of  standing  guard  and  hold- 
ing the  vesical  outlet  closed.  By  others  it  is  claimed  that  this 
musculo-elastic  ring  hinders  the  entrance  of  urine  into  the  urethra, 
but  that  the  tension  of  the  bladder-walls  when  the  organ  is  tilled 
overbalances  this  elasticity,  and  a  drop  of  urine  escaping  into  the 
urethra  brings  the  necessity  for  urination  to  the  senses,  and  the  act 
then  becomes  a  voluntary  one. 

It  has  been  found,  however,  in  cases  of  urettro-cystic  vaginal  fist- 
ula, where  the  upper  part  of  the  urethra  and  neck  of  the  bladder 
were  totally  destroyed,  that,  after  the  healing  of  the  parts,  the  an- 
terior or  lower  end  of  the  urethra  was  practically  able  to  control  the 
urine. 

The  act  of  emptying  the  bladder  is  a  very  important  and  inter- 
esting process,  and  is  not  so  simple  as  might  at  first  be  imagined. 
As  the  organ  has  three  openings  and  is  emptied  by  the  concentric 
contraction  of  its  muscular  coat,  the  urine  is  not  only  expelled 
through  the  urethra,  but  there  is  a  tendency  to  regurgitation  or 
backward  pressure  of  the  fluid  into  the  ureters.  The  backward 
flow  is  effectually  prevented  by  a  very  complete  and  interesting  ar- 
rangement. The  protection  is  threefold  :  First,  by  the  oblique  direc- 
tion that  the  ureters  take  in  piercing  the  vesical  wall ;  second,  by  the 
two  muscular  slips  already  mentioned,  that  pass  from  the  sphincter 
vesicae  to  the  insertions  of  the  ureters.  As  the  bladder  gradually 
fills  these  slips  are  tightly  drawn,  and  thus  partially  or  wholly  close 
the  ureteric  orifices.  Moreover,  it  may  be  presumed  that  as  these 
muscular  fasciculi  have  their  origin  in  the  vesical  neck,  they  act 
most  vigorously  during  urination,  when  the  bladder  pressure  tends 
to  cause  regurgitation  into  the  ureters.  Their  greatest  use  is,  in  all 
probability,  during  the  act  of  mictm'ition.  This  view  is  borne  out 
by  the  fact  that  these  little  muscles  are  in  a  rudimentary  condition 
in  the  female,  the  urethra  being  shorter  and  the  force  necessary  to 
empty  the  bladder  much  less  than  in  the  male ;  and  further,  by  the 
well-known  fact  that  when  the  hypertrophy  of  the  muscular  walls 
of  the  female  bladder  does  occur,  these  fasciculi  are  proportionately 
enlarged.  Third,  by  a  ligamentous  band,  not  described  in  the  text- 
books of  anatomy,  which  runs  from  one  ureteric  opening  to  the 
other,  inclosing  their  vesical  ends,  and  is  kno'wn  as  the  inter-ureteric 


FUNCTION   OF   TOE   BLADDER.  649 

ligament.  Its  mode  of  action  is  this :  as  the  bladder  gradually 
fills,  the  openings  of  the  ureters  are  carried  farther  a^jart,  and  with 
them  the  ends  of  the  ligament.  Being  elastic  it  yields  to  a  certain 
extent,  and  after  a  time^  being  able  to  yield  no  more,  pulls  upon 
both  openings,  closing  them  more  or  less  completely.  During  urin- 
ation the  tension  of  the  ligament  gradually  decreases,  and  then  the 
muscular  fasciculi  and  the  oblique  direction  in  which  the  ureters 
enter  the  bladder  come  into  play,  the  ligament  being  of  use  only 
during  filling  and  distention. 

If  from  any  cause  the  bladder  is  not  emptied  at  the  proper  time, 
the  organ  is  not  only  injured  by  overdistention,  but  more  serious 
results  may  follow  if  the  retention  continues  for  some  time  ;  although 
the  bladder  is  too  full  to  receive  any  more  urine,  the  kidneys  con- 
tinue to  secrete  until  not  only  the  bladder,  but  also  the  ureters, 
renal  pelves,  and  kidney-tubes  become  overfilled.  When  the  press- 
ure on  the  urinary  side  of  the  Malpighian  tuft  equals  that  of  the 
blood-stream  in  the  glomerulus,  secretion  of  urine  at  once  ceases,  and 
we  have  a  mechanical  suppression.  After  death  the  bladder,  ureters, 
and  renal  pelves  are  found  to  be  greatly  distended,  and  the  kidney 
pale,  of  a  bluish,  pearly  color  in  the  cortex,  and  oozing  urine  from 
the  cut  surface. 

Maas  and  Punier  ("  ^ew  York  Medical  Kecord,"  October  1, 1881) 
have  performed  experiments  on  animals  and  men  which  demon- 
strate to  their  satisfaction  that  the  bladder,  whether  healthy  or  dis- 
eased, as  well  as  the  urethra,  possesses  the  faculty  of  absorption  in  a 
greater  or  less  degree,  varying  with  the  substance  used.  Their 
methods  when  experimenting  on  animals  were  as  follows :  The 
bladder  was  fully  exposed,  both  ureters  tied  about  half  an  inch 
above  their  termination,  then  divided  above  the  ligatures,  and  the 
urine  conducted  outside  of  the  body  by  means  of  glass  cannulse  in- 
troduced into  the  central  ends.  The  bladder  was  then  evacuated  by 
a  catheter  through  which  the  solution  experimented  with  was  in- 
jected, the  catheter  withdrawn,  and  a  ligature  drawn  tightly  around 
the  urethra  between  the  prostate  gland  and  the  neck  of  the  bladder ; 
sometimes  after  tying  the  ureters  a.nd  urethra  the  bladder  was  emp- 
tied by  a  Pravaz  syringe,  the  medicated  solution  injected  tlirough 
the  cannula  of  the  latter  and  the  puncture  closed  by  ligature. 

In  a  second  series  of  experiments  the  abdominal  cavity  was  not 
opened,  but  after  drawing  off  the  urine  the  solution  was  injected 
through  the  catheter,  and  the  mouth  of  the  latter  plugged.  The 
substances  used  were  ferrocyanide  of  potassium,  salicylate  of  soda, 
cyanide  of  potassium,  strychnine,  atropine,  curare,  apomorphia,  and 


650  DISEASES  OF   WOJIEN. 

pilocarpin.  All  of  these  substances  were  absorbed,  but  some  so 
slowly  that  their  physiological  action  was  not  manifested ;  thus  atro- 
pine seemed  to  have  no  effect  upon  the  animal,  but  a  small  (piantity 
of  its  urine  collected  during  the  continuance  of  the  experiment  and 
instilled  into  the  eye  of  another  animal  rapidly  caused  dilatation  of 
the  pupil.  The  diseased  bladder  wtis  also  found  capable  of  absorb- 
ing the  same  substances. 

In  their  experiments  on  man,  Maas  and  Punier  used  iodide  of 
potassium  and  pilocarpin.  As  regards  the  excretion  of  the  former, 
they  call  attention  to  the  fact  that  in  some  individuals  it  rapidly 
passes  off  by  the  urine,  in  others  by  the  saliva,  and  in  others  by  only 
one  of  these  paths  to  the  exclusion  of  the  other.  The  method  used 
was  the  following :  Taking  only  individuals  with  healthy  bladders, 
the  latter  were  evacuated  by  a  Nelaton  catheter,  after  which  in 
twenty-eight  cases  they  injected  fifty  grammes  of  a  ten-per-cent  so- 
lution of  iodide  of  potassium,  following  this  up  in  thirteen  other 
cases  with  an  injection  of  one  or  two  centigrammes  of  muriate  of 
pilocarpin  half  an  hour  later.  The  iodide  was  detected  in  the  saliva 
in  lifty-seven  per  cent  of  the  first,  and  seventy-seven  per  cent  of 
the  second  series,  but  usually  in  small  quantities  only.  The  dis- 
eased bladder  was  found  to  absorb  much  more  promptly ;  iodide  of 
j)otassium  was  detected  in  the  saliva  when  only  2*0  were  used.  A 
solution  of  0'4  morphine  in  2*0  of  distilled  water  used  in  this  way, 
acted  very  plainly  as  an  anodyne.  Pilocarpin  made  up  into  a  bougie 
with  cocoa-butter,  and  introduced  into  the  urethra  (both  healthy  and 
diseased),  manifested  its  specific  effects. 

L.  Schafer  found  that  after  producing  vesico-vaginal  fistulae  in 
animals  there  was  increase  of  from  two  to  three  per  cent,  and  some- 
times from  four  to  five  per  cent,  in  the  amount  of  urine  passed  over 
that  passed  before  the  fistulae  were  made;  and  he  feels  convinced 
that  under  normal  conditions  of  urinary  secretion  the  amount  of 
urine  in  the  bladder  is  gradually  diminished  by  a  slight  though  reg- 
ular absorption  of  its  watery  elements.  If  this  be  true,  we  may 
look  to  a  too  rapid  absorption  as  one  of  the  causes  of  gravel  and 
urinary  calculi. 

On  the  other  hand,  however,  Susini  found  that  after  injecting 
jDotassium  iodide  and  belladonna  into  his  own  bladder,  and  retaining 
them  for  many  hours,  no  trace  of  the  former  was  found  in  tlie  saliva, 
and  no  appearance  of  the  specific  action  of  the  latter  was  made  man- 
ifest. Ailing  agrees  with  Susini,  and  the  experiments  of  P.  Dubelt 
also  support  this  view.  After  careful  consideration  of  the  evidence 
pro  and  con^  I  am  strongly  inclined  to  the  ^dew  that  the  bladder 


FUNCTION  OF  THE  BLADDER.  G51 

does  not  absorb  anything,  save  possibly  a  little  water,  unless  its 
epithelial  surface  is  displaced  or  destroyed.  When  abrasion  does 
occur,  absorption  is  ra[)i(l  and  its  effects  marked.  The  fact  that  the 
mucous  membrane  of  the  bladder  is  able  to  absorb  liquids  after  ero- 
sion of  its  epithelium  throws  much  light  on  the  cause  of  some  of 
those  peculiar  constitutional  symptoms  accompanying  chronic  cysti- 
tis, and  known  by  some  authors  as  annnonasmia. 

The  inner  surface  of  the  bladder  is  lubricated  by  a  very  thin  se- 
cretion of  mucus.  This  can  be  demonstrated  by  putting  some  fresh, 
normal  urine  in  a  clean  bottle.  In  a  short  time  a  slight  hazy  cloud 
will  settle  to  the  bottom.  When  examined  microscopically  it  will 
be  found  to  consist  of  a  few  epithelial  scales  and  mucous  fibrillse — 
long,  fine,  and  often  interlacing.  In  disease  this  secretion  becomes 
greatly  increased,  and  is  then  thick,  viscid,  and  ropy.  The  normal 
secretion  when  tested  chemically  is  found  to  contain  an  abundance 
of  the  earthy  and  alkaline  phosphates. 

A  healthy  woman  urinates  from  four  to  six  times  in  every  twen- 
ty-four hours,  and  passes  in  all  from  thirty-five  to  sixty  ounces  of 
urine,  the  average  being  about  forty-live  ounces.  The  amount 
passed  varies  much  with  the  season  of  the  year,  more  being  passed 
in  winter  than  in  summer ;  it  varies  also  with  the  amount  of  fluid 
ingesta,  rest,  and  exercise.  Neither  limpid  nor  concentrated  urine 
are  well  borne  by  the  bladder. 

The  pressure  of  the  urine  in  the  bladder  being  of  importance  in 
both  health  and  disease,  I  deem  it  advisable  to  give  here  the  results 
of  some  experiments  by  Schatz,  Odelbrecht,  Hegar,  and  Dubois. 
These  experiments  were  made  with  the  manometer,  an  instrument 
which  by  means  of  a  column  of  mercury  may  be  adapted  to  regis- 
ter the  exact  pressure  in  the  bladder. 

They  found  the  pressure  to  be  from  twelve  to  sixteen  inches 
while  standing,  in  the  recumbent  posture  it  was  only  from  four  to 
six  inches.  The  pressure  in  the  recumbent  position  Dubois  be- 
lieved to  be  due  not  to  visceral  pressure  from  above,  but  to  the  nat- 
ural tonicity  of  the  distended  organ ;  for  in  the  cadaver,  after  re- 
moving the  other  viscera,  the  pressure  in  the  bladder  indicated  four 
inches,  plainly  due  to  the  elasticity  of  the  organ  itself.  The  same 
has  been  observed  in  cystocele,  in  which  the  visceral  pressure  is  also 
absent. 

The  pressure  is  about  the  same  in  both  sexes,  and  at  all  ages.  It 
was  found  to  rise  from  one  half  to  one  inch  with  each  inspiration, 
and  to  fall  about  the  same  with  each  expiration.  In  laughing, 
coughing,  etc.,  it  rose  as  high  as  from  twenty  to  sixty  inches.     In 


652  DISEASES  OF  WOMEN. 

diseases  of  the  spinal  cord,  such  as  myelitis,  and  after  injuries  to 
the  vertebroe,  Dubois  found  a  marked  decrease  in  bladder  pressure. 
These  curious  observations  on  the  varying  degrees  of  pressure 
arising  from  change  of  posture  are  not  without  value.  They  help 
one  to  understand  why,  in  some  diseases  of  the  bladder,  patients 
should  maintain  the  recumbent  position. 


CHAPTEE  XXXYIL 

FUNCTIONAL   DISEASES    OF    THE   BLADDER. 

It  has  been  the  rule  among  pathologists  to  class  under  the  head 
of  functional  diseases  all  those  in  which  no  lesion  of  structure  was 
discoverable  in  the  organs  concerned.  Although  we  are  still  obliged 
to  accept  this  nomenclature,  the  progress  of  pathological  knowledge 
in  the  past  few  years  has  weeded  out  many  of  the  so-called  functional 
affections :  and  as  this  knowledge  advances,  and  new  and  efficient 
means  for  observation  and  study  arise,  we  shall  be  able  to  root  out 
many  more,  thus  doing  away  with  much  of  the  vagueness  and  uncer- 
tainty in  which  this  class  of  affections  is  shrouded.  But  even  with 
the  improved  facilities  for  diagnosis  at  our  command,  there  are  still 
many  diseases  in  this  list.  Owing  to  the  obscurity  at  present  sur- 
rounding the  subject  of  reflex  or  sympathetic  disorders,  i.  e.,  the 
abnormal  condition  of  an  organ  or  organs,  near  or  distant,  affecting 
the  function  or  nutrition  of  another  organ,  we  are  obliged  to  put 
these  affections  in  this  class  also.  Under  this  head  then  will  be 
considered : 

I.  Derangements  of  function  in  which  there  is  no  recognizable 
organic  lesion. 

II.  Derangements  of  function  due  to  diseases  of  the  nutritive 
and  nei-vous  systems,  and  to  abnormal  conditions  of  the  urine  re- 
sulting therefrom. 

III.  Derangements  of  function  due  to  inflammatory  and  other 
affections  of  the  pelvic  organs,  such  as  metritis  and  pelvic  perito- 
tonitis. 

It  will  be  observed  that  in  this  arrangement  of  the  subject,  al- 
though a  number  of  structural  diseases  are  considered,  they  aU 
stand  in  a  causative  relation  to  the  disturbed  action  of  the  bladder, 
the  latter  being  free  from  any  organic  lesion,  and  only  disturbed  in 
the  discharge  of  its  duty  by  influences  outside  of  itself. 

Before  discussing  these  functional  disorders  in  detail,  it  will  be 


654  DISEASES  OF  WOMEN. 

necessary  to  fix  clearly  in  the  mind  their  various  manifestations ; 
these  are :  frequent  urination,  or  polyuria ;  difficult  urinati<jn  and  re- 
tention, or  ischuria  ;  painful  urination,  or  dysuria  ;  pain  after  urina- 
tion, or  vesical  tenesmus;  and  incontinence  of  urine,  or  enuresis. 
These  deranj^ed  actions  may  also  be  due  to  organic  diseases  of  the 
bladder,  but  they  will  at  present  only  be  discussed  in  connection 
with  the  three  classes  of  functional  derangements  of  that  organ  just 
referred  to  : 

I.  Derangements  of  function  in  which  there  is  no  Recognized 
organic  lesion.  There  are  five  of  these  derangements  which  demand 
special  consideration. 

1.  Neuroses,  pure  and  simple. 

2.  Derangements  due  to  hysteria. 

3.  Derangements  due  to  disorders  of  the  sexual  function. 

4.  Derangements  due  to  malaria. 

5.  Derangements  due  to  ovarian  affections. 

1.  Neuroses. — By  this  term  I  refer  to  purely  nervous  affections 
of  this  organ.  They  are  rather  rare,  it  is  tme,  but  that  they  do  ex- 
ist there  is  no  doubt,  for  there  are  certain  conditions  that  seem  to 
depend  on  no  other  known  pathological  cause. 

We  learn  from  the  books  that  vesical  neuralgia  is  of  this  class. 
It  is  known  by  a  variety  of  names,  each  taking  as  its  key-note  some 
peculiar  manifestation  or  symptom,  as  irritable  bladder,  cystospasm, 
cystoplegia,  and  neuralgia  vesicae. 

The  term  irritability  so  commonly  used  in  speaking  of  the 
healthy  organ  must  not  be  confounded  with  the  condition  known  as 
irritable  bladder.  The  former  refers  to  a  certain  property  that  the 
viscus  possesses,  by  means  of  which  it  is  able  to  respond  to  certain 
stimuli,  while  the  latter  refers  to  an  abnormal  condition  of  sensation, 
viz.,  super-sensibility,  or  hyperaesthesia. 

2.  Derangements  due  to  Hysteria. — Hysteria  holds  a  prominent 
place  among  the  causes  of  functional  derangement  of  the  bladder, 
the  vesical  affection  being  probably  only  a  fragment  of  a  general 
neurosis.  Acute  and  chronic  diseases  of  the  brain  and  spinal  cord 
also  produce  various  vesical  difliculties  of  this  nature,  but  tliese  will 
be  discussed  under  another  class.  Any  one  who  has  suffered  the 
mortification  of  an  involuntary  evacuation  of  urine  from  fear,  will 
understand  how  the  brain  and  nervous  system  can  influence  the 
bladder. 

In  the  variety  of  conditions  grouped  under  the  head  of  hysteria, 
it  is  often  observed  that  frequent  urination  is  a  prominent  symptom. 
The  cause,  in  many  cases,  is  the  peculiar  character  of  the  urine  se- 


FUNCTIONAL  DISEASES   OF  THE  BLADDER.  655 

creted  in  this  disturbed  condition  of  the  nervous  system.  The  lim- 
pid urine  of  hysterical  patients  is  deficient  in  solids,  the  watery  por- 
tion being  greatly  in  excess.  This  unnatural  composition  renders 
the  urine  irritating  to  the  bladder  so  that  it  can  not  be  long  retained. 
The  quantity  of  urine  secreted  is,  at  certain  times,  excessive,  which, 
together  with  its  irritating  quality,  renders  urination  necessarily 
very  frequent. 

But  apart  from  the  frequent  urination  which  occurs  in  severe 
attacks  of  hysteria  due  to  the  conditions  just  mentioned,  cases  are 
often  seen  of  frequent  micturition  which  can  only  be  accounted  for 
by  the  state  of  the  nerves  which  govern  the  action  of  the  bladder. 
When  the  quantity  and  composition  of  the  urine  are  normal,  and  the 
patient  can  retain  it  without  pain  or  distress  during  the  night,  but 
has  to  pass  it  every  hour  or  two  during  the  day,  it  may  safely  be 
presumed  that  the  trouble  is  functional,  and  due  to  a  disordered 
state  of  the  nervous  system.  The  only  condition  which  resembles 
this  history  is  occasionally  seen  in  prolapsus  uteri,  the  patient  being 
free  from  trouble  while  reclining,  but  having  to  urinate  frequently 
when  in  the  erect  position. 

Hysterical  patients  frequently  suffer  from  retention  of  urine. 
Some  of  them  complain  for  a  time  of  difficulty  in  emptying  the 
bladder,  and  finally  fail  to  do  so  altogether.  At  other  times  they 
suddenly  find  that  they  can  not  urinate.  There  are  conflicting 
views  regarding  the  cause  of  this  retention,  some  believing  that  such 
patients  can  not  urinate,  and  others  that  they  will  not.  Tliose  who 
believe  that  the  trouble  is  feigned  and  not  real,  do  so  on  the  ground 
that  in  this  morbid  state  of  the  nervous  system  the  patients  enjoy 
catheterization,  which  would  be  distressing  to  any  one  of  healthy 
mind  and  body.  Others  claim  that  in  the  extreme  sexual  excite- 
ment which  occurs  in  some  cases  of  hysteria,  the  chronic  erection 
of  the  clitoris  makes  pressure  upon  the  urethra,  and  prevents  the 
flow  of  the  urine  through  the  canal  which  is  at  that  time  com- 
pressed. 

I  am  satisfied  that  both  kinds  of  cases  occur.  There  are  those 
who  complain  of  retention  when  they  know  that  the  doctor  will  use 
the  catheter,  but  they  can  urinate  easily  when  they  please.  Others 
I  have  seen  who  were  suffering  from  excessive  and  painful  disten- 
tion of  the  bladder  and  would  have  gladly  relieved  themselves  if 
they  could. 

3.  Derangements  due  to  Disorders  of  the  Sexual  Function. — An- 
other class  which  resembles  the  hysterical  patients  in  the  frequency 
of  urination,  but  differs  in  every  other  respect,  is  found  in  those 


656  DISEASES  OF   WOMEN. 

M'ho  suffer  from  the  liabit  of  niastur])ation.  The  constant  conges- 
tion and  irritabihty  of  tlie  pelvic  organs,  caused  aud  kept  up  by  the 
unnatural  and  excessive  exercise  of  the  sexual  function  give  rise  to 
frequent  urination.  Such  patients  complain  of  general  weakness, 
which  is  not  accounted  for  by  any  organic  disease  of  the  general 
system.  Nor  is  there  disease  of  the  bladder ;  it  is  simply  enfeebled 
and  irritable  like  the  rest  of  the  pelvic  organs.  To  make  a  correct 
and  i^ositive  diagnosis  in  such  cases  is  by  no  means  easy,  because  it  ne- 
cessitates our  detecting  the  habit  of  masturbation,  and  this  is  usually 
one  of  the  most  difficult  tasks  for  tlie  diagnostician.  It  is  not  al- 
ways prudent  to  question  the  patient  regarding  the  habit ;  and  even 
when  that  is  done  they  frequently  fail  to  comprehend  the  question, 
or  they  answer  falsely  in  the  negative.  The  physician  is  thus  gen- 
erally left  to  guess  at  the  truth  of  the  matter. 

The  sjTnptoms  developed  by  masturbation  are  depression  of  the 
nervous  system,  manifested  by  lassitude,  sadness,  or  emotional  ex- 
pressions of  joy  aud  sorrow,  those  affected  "vnth  this  liabit  being  easily 
affected  to  smiles  or  tears.  The  eyes  are  dreamy  and  heavy,  and  the 
pupils  dilated.  Such  subjects  are  excitable,  irritable,  and  easily  ex- 
liausted.  They  often  have  headaches.  Nutrition  is  apparently  good 
in  some  cases,  as  is  sbown  by  the  fair  supply  of  flesh ;  stiU,  they  often 
suffer  from  acute  indigestion,  although  at  times  the  appetite  is  re- 
markably good.  The  bowels  are  usually  constipated,  and  the  mus- 
cles soft  and  flabby.  The  exhalations  from  the  skin  are  some- 
times changed,  so  that  a  peculiar  odor  is  noticeable  about  such  persons- 
This  odor  can  not  be  described,  but,  when  once  recognized,  is  easily 
remembered. 

In  this  variety  of  functional  derangement  of  the  bladder,  as  well 
as  in  all  the  other  varieties  of  neurotic  affections,  the  symptoms  vary 
in  severity  to  a  great  extent  in  the  same  individual.  The  trouble  is 
by  no  means  regular  and  constant  in  its  manifestations,  as  in  organic 
diseases.  Whatever  disturbs  the  nervous  system  will  increase  the 
disorder.  The  rule  is  that  frequent  urination  is  the  prominent  s}Tnp- 
tom,  but  occasionally  painful  micturition  is  complained  of.  It  is 
then  simply  a  slight  scalding  pain,  experienced  when  the  urine  is 
passing  over  the  irritable  or  chafed  mucous  membrane  about  the 
meatus  urinaria?. 

4.  Derangements  due  to  Malaria. — Another  cause  which  I  believe 
acts  through  the  nervous  system  is  malaria.  The  effect  of  malarial 
poison  on  the  bladder  and  urethra  is  very  peculiar.  The  trouble 
produced  in  this  way  has  been  called  urethral  fever,  and  is  described 
as  an  inflammation  of  the  mucous  membrane  of  that  canal.    It  might 


FUNCTIONAL  DISEASES  OF  THE  BLADDER.  657 

more  properly  be  called  malarial  fever  of  the  urethra.  As  I  have 
observed  this  aifectiou,  the  bladder  and  urethra  are  usually  both 
affected,  but  I  do  not  consider  the  disease  one  of  a  well-defined  in- 
tlauiniatory  character.  There  are  usually  symptoms  of  malaria  pres-  ' 
cut,  but  not  necessarily  chill  and  fever.  On  the  contrary,  I  believe 
that  I  have  observed  the  aii'ection  more  frequently  in  remittent  than 
in  intermittent  fever,  and  very  often,  where  the  constitutional  symp- 
toms were  not  more  than  a  slight  derangement  of  the  digestive 
organs,  with  moderate  elevation  of  temperature  in  the  after-part  of 
the  day. 

The  symptoms  vary,  ];)ut  usually  are  as  follows  :  The  patient  com- 
plains of  frequent  desire  to  urinate,  and  some  vesical  tenesmus ;  se- 
vere burning  pain  on  passing  water,  with  stinging  and  burning  in 
tlie  urethra  after  urination.  The  history  of  such  cases  resembles 
acute  gonorrhoeal  urethritis  so  far  as  the  abruptness  of  the  attack  and 
the  tenderness  and  pain  of  the  urethra  are  concerned,  but  there  is 
usually  no  discharge,  or,  at  least,  very  little.  In  many  cases  the 
suffering  is  greatest  in  the  afternoon  and  early  part  of  the  night. 
Under  proper  treatment  the  disease  disappears  as  promptly  as  it 
comes  on. 

5.  Derangements  due  to  Ovarian  Affections. — In  disease  of  the 
ovaries  we  sometimes  find  that  the  bladder  suffers  very  much  from 
deranged  nerve  action.  The  clearest  and  best  account  of  this  form 
of  functional  bladder  trouble  is  given  by  Fothergill  in  his  paper  on 
'•Ovarian  Dyspepsia,"  published  in  the  "American  Journal  of  Ob- 
stetrics," January,  1878.  In  speaking  of  the  derangement  of  the 
stomach  and  pelvic  organs,  he  says :  '•  It  soon  became  clear  that  there 
was  some  condition  existing  which  stood  in  a  causative  relation  to 
both  the  dyspepsia  and  the  uterine  distm-bance.  That  condition  was 
quickly  seen  to  be  a  state  of  vascular  excitement  in  one  or  both  ova- 
ries, usually  the  left  ovary.  This  condition  Barnes  terms  '  oophoria.' 
in  this  state  there  is  always  more  or  less  pain  constantly  in  the  iliac 
fossa,  more  rarely  on  the  right,  much  aggravated  at  the  cataraenial 
periods,  when  the  pain  shoots  from  the  turgid  ovary  dovra  the  thigh 
of  the  corresponding  side  along  the  genito-crural  nerve.  This  pain- 
ful state  is  otherwise  known  as  'ovarian  dysmenorrho&a.'  When 
pressure  is  made  over  this  tender  ovary  during  the  catamenial  flow, 
acute  pain  is  experienced.  Pressure  also  elicits  pain  during  the  inter- 
menstrual intei"val.  At  the  same  time  that  acute  pain  is  felt,  evi- 
dence is  furnished  of  emotional  psrturbation  ;  the  patient  feels  as  if 
about  to  faint,  or  '  feels  queer  all  over,'  as  some  express  it,  and  the 
changes  in  the  patient's  countenance  speak  of  something  more  than 


658  DISEASES  OF  WOMEN. 

more  pain,  pure  and  simple.  It  is  evident  there  is  a  wave  of  uerve- 
pertm-bation  set  up,  which  excites  more  than  the  sensation  of  pain. 
Commonly  the  patient  feels  sick  after  the  momentary  pressure,  and 
asks  to  be  permitted  to  sit  down,  alleging  that  she  feels  sick  and 
faint.  If  a  careful  physical  examination  be  made,  it  will  be  found 
that  there  is  an  enlarged  and  tender  ovary,  which  may  sometimes  be 
caught  betwixt  the  linger  in  the  vagina  and  the  lingers  of  tlie  other 
hand  applied  to  the  abdominal  wall  of  the  ovary.  Such  manipula- 
tion elicits  manifestations  of  acute  suffering  from  the  patient.  Fre- 
quently the  rectus  muscle  over  the  tender  ovary  is  hard  and  rigid, 
so  as  to  place  the  organ  as  perfectly  at  rest  as  is  possible ;  just  as  we 
see  the  rectus  to  stiffen  and  become  rigid  over  the  liver  when  there 
is  an  hepatic  abscess,  and  thus  to  secure  rest,  as  regards  movement, 
for  that  viscus.  .  .  . 

"Not  rarely,  too,  there  is  set  up  a  very  distressing  condition,  viz., 
that  of  recurring  orgasm.  This  occurs  most  commonly  during  sleep 
— '  the  period  par  excellence  of  reflex  excitability.'  In  more  aggra- 
vated cases  it  also  occurs  during  the  waking  moments,  and  this  it 
does  without  any  reference  to  psychical  conditions. 

"  The  centers  of  the  pelvic  viscera  lie  near  together  in  the  cord, 
and  the  condition  of  one  is  I'eadily  communicated  to  another.  The 
brief  recurrent  orgasm  affects  the  bladder-centers,  and  the  call  to 
make  water  is  sudden  and  imperative,  and  must  be  attended  to  at 
once,  or  a  certain  penalty  be  paid  for  non-attention.  This  last  is  not 
a  common  condition,  fortunately,  but  it  is  a  source  of  great  suffering, 
bodily  and  mental,  when  it  does  occur.  The  condition  of  the  ovary 
also  acts  reflexly  upon  the  uterus,  and  keeps  it  in  a  state  of  persistent 
erection  and  high  vascularity,  with  the  normal  phenomena  attendant 
thereupon." 

It  is  evident  that  this  form  of  bladder  trouble  can  only  be  re- 
lieved by  treatment  of  the  ovarian  disease,  for  which  bromide  of 
potassium  and  counter-irritation  are  very  serviceable,  with,  of  course, 
attention  to  the  general  health. 

Sijmjytomatology. — In  all  of  these  nei-vous  affections  of  the  urin- 
ary organs,  pain  and  a  feeling  of  weight  and  uneasiness  in  the  region 
of  the  bladder  are  usually  present.  Still,  the  most  constant  and  dis- 
tressing symptom  is  the  frequent  and  i)ainful  desire  to  micturate, 
which  the  patient  tries  to  relieve  by  frequent  urination,  a  few  drops 
only  being  passed  at  a  time.  Of  course,  there  are  varying  grades  of 
this  affection,  in  some  of  which  these  symptoms  are  by  no  means  so 
troublesome.  In  some  extreme  cases,  when  a  little  urine  collects  in 
the  bladder,  the  pain  and  irritability  are  so  intense  that  it  is  spurted 


FUNCTIONAL   DISEASES   OF   THE    BLADDER.  659 

out  by  a  very  forcible  and  painful  contraction  of  the  organ.  Tlie 
sense  of  weight  and  bearing  down  are  most  intense  in  the  upright 
position.  The  pains  may  be  confined  to  the  neck  or  base  of  the 
bladder,  or  they  may  shoot  in  all  directions.  The  pain  in  micturition 
may  be  present  at  the  beginning,  but  is  usually  most  severe  during 
and  after  the  completion  of  the  act. 

The  local  pain  and  distress,  with  the  frequent  urination  and  un- 
rest, react  upon  the  general  nervous  system,  thereby  greatly  aggra- 
vating the  original  disorder.  This  lowered  systemic  condition  in 
turn  aifects  the  local  disorder,  and  so  the  one  is  continually  aggra- 
vating the  other.  In  this  way  the  patient,  if  not  relieved,  goes  on 
from  bad  to  worse,  until  the  host  of  phenomena  characteristic  of 
nervous  prostration  and  general  ill-health  are  developed. 

In  certain  cases  the  sufferers  are  by  no  means  so  badly  circum- 
stanced, but  time  and  neglect  tend  to  produce  these  results  sooner 
or  later.  In  some  cases,  again,  the  suffering  gradually  disappears, 
and  the  patient  is  restored  to  health  ^\dthout  much  aid  from  treat- 
ment.    The  trouble  appears  to  wear  itself  out. 

Diagnosis. — The  symptoms  I  have  given  are  by  no  means  pathog- 
nomonic of  these  affections,  the  same  being  produced  by  organic 
disease  of  the  bladder,  calculi,  and  various  other  causes.  The  diag- 
nosis must  be  made  by  exclusion.  The  first  thing  to  do  is  to  make 
a  careful  microscopical  and  chemical  analysis  of  the  urine.  JSTot  only 
can  local  organic  trouble  be  thus  eliminated,  but  important  knowl- 
edge as  to  the  state  of  the  general  system  obtained. 

If  no  urinary  abnormality  is  discovered,  a  careful  external  and 
internal  examination  of  the  organ  itself  should  be  made.  A  finger 
should  first  be  passed  into  the  vagina,  and  an  endeavor  made  to  ascer- 
tain, by  pressure  on  the  vesi co-vaginal  septum,  whether  there  is  any 
abnormal  sensitiveness  of  the  vesical  base  or  neck,  or  of  both.  Then 
the  sensibility  of  the  mucous  membrane  should  be  tested  by  the  in- 
troduction of  a  sound. 

If  sufficient  cause  be  not  found  in  either  the  urine  or  the  bladder, 
the  case  may  be  set  down  as  one  of  pure  neurosis,  to  be  treated  as  I 
shall  hereafter  describe.  Systemic  conditions,  such  as  hysteria  or 
chlorosis,  should  be  considered,  as  they  point  to  a  tendency  to  neu- 
rotic difficulties,  liable  to  be  localized. 

Prognosis. — As  a  rule,  the  prognosis  is  favorable.  This,  how- 
ever, is  not  always  the  case.  The  longer  the  affection  has  lasted,  the 
more  difficult  it  is  to  cure.  Most  cases  may  be  cured  in  a  few  weeks' 
time,  and  even  the  most  obstinate  in  a  few  months.  The  danger  to 
the  patient  lies  in  the  fact  that  continuance  of  the  disorder  is  liable 


660  DISEASES  OF   WOMEN. 

to  bring  on  an  organic  lesion,  and,  whether  this  resuhs  or  not,  the 
reaction  on  the  general  system  tends,  in  the  worst  cases,  to  produce 
hypochondriasis  or  even  melancholia. 

Causation. — These  nervous  affections  of  the  bladder  occur  most 
frequently  in  tliose  of  the  nervous  temperament.  A  highly  devel- 
oped nervous  system  predisposes  one  to  nervous  aifections  of  all 
kinds.  Especially  is  this  the  case  if  the  subject  is  not  well  sustained 
by  a  vigorous  nutritive  system.  Tliose  in  whom  the  emotional  ele- 
ments predominate  in  the  mental  composition  are  more  liable  to 
nervous  affections  of  the  bladder  than  those  of  the  more  intellectual 

type. 

The  exciting  causes  include  all  influences  which  depress  or  ex- 
haust the  nervous  system.  Mental  taxation  or  excitement  which 
tends  to  increase  the  excitability  of  the  nervous  system  may  derange 
the  function  of  the  bladder.  Constitutional  diseases  which  lower  the 
tone  of  the  w^hole  organization  also  tend  to  produce  the  affections 
now  under  discussion. 

It  is  not  possible  to  give  any  satisfactory  explanation  of  the  reason 
why  the  innervation  of  the  bladder  becomes  deranged  in  some  ])er- 
sons  from  causes  which  are  in  others  inoperative.  It  may  be  that 
those  who  are  most  susceptible  to  this  cause  are  so  because  of  some 
inherited  sensitiveness  of  the  pelvic  organs  which  responds  to  the 
disturbing  influences.  This  appears  to  be  the  case  with  those  who 
suffer  from  irritation  of  the  bladder  caused  by  ovarian  disease.  This 
is  apparent  from  the  fact  that  one  affected  with  disease  of  the  ovaries 
will  suffer  from  derangement  of  the  function  of  the  stomach,  while 
another  having  a  similar  ovarian  affection  will  suffer  most  from  fre- 
quent urination. 

E.eg'ardino;  the  causative  relations  of  malaria  to  irritation  of  the 
bladder,  all  that  can  be  said  at  the  present  time  is  that  this  mat<  rles 
7rior})i  ap])ears  to  act  upon  that  viscus  tlu'ougli  the  nervous  system. 

Treatment. — This  may  be  classed  as  general  and  local.  In  pure 
neuroses,  attention  should  be  first  directed  to  improving  the  general 
condition  of  the  patient.  Cheerful  company  should  be  provided  at 
meals  and  at  other  times,  and  there  should  be  exercise  suited  to  the 
strength  of  the  patient,  daily  al)lution,  and  proper  regulation  of  diet. 
This  latter  should  be  simple  and  nourishing,  and  of  a  kind  calculated 
to  produce  as  little  urea  and  urinary  solids  as  possible.  In  cases 
where  the  urine  is  limpid,  the  opposite  course  is  to  be  pursued. 
Pastry,  irritating  condiments,  and  stimulants,  except  in  rare  cases, 
should  be  prohibited.  The  exception  to  this  is  where  a  condition 
of  the  system  calling  for  stimulation  exists.    In  such  cases  the  irrita- 


FUNCTIONAL  DISEASES   OF  THE   BLADDER.  GGl 

tion  of  the  bladder  produced  by  their  use  may  be  more  than  counter- 
balanced by  the  good  they  do  tbe  general  system.  Tea  is  better  than 
coffee,  but  neither  is  to  be  used  in  any  great  quantity. 

The  condition  of  the  urinary  secretion  must  be  carefully  watched, 
and  any  al)norn]ality  quickly  and  judiciously  corrected.  Where  there 
is  any  tendency  to  excessive  acidity,  the  effervescing  waters,  rich  in 
carbonic-acid  gas,  will  be  found  of  use. 

The  bowels  should  be  kept  moderately  well  open,  but  should 
never  be  irritated  with  active  cathartic  agents. 

Tonics  and  medicinal  gtinmlants  are  often  of  great  value  when 
judiciously  exhibited.  Strychnia  in  very  small  doses  does  not,  as 
might  be  supposed,  aggravate  the  irritable  condition  of  these  organs. 
The  nerve-tone  being  below  par,  strychnia,  by  gradually  increasing 
it,  is  of  great  service.  In  large  doses  it  is  undoubtedly  hurtful,  and 
should  never  be  long  continued.  Quinine,  iron,  and  the  various  sim- 
ple and  compound  vegetable  bitters  act  well  in  the  cases  where  their 
exhibition  is  indicated. 

If  the  irritation  is  extreme,  various  soothing  emulsions  and  de- 
coctions may  be  given  by  the  mouth.  Of  these,  preparations  of 
marshmallow,  triticum  repens,  acacia,  pareira  brava,  and  buchu  act 
well.  Emulsio-amygdalse  is  much  used  and  highly  recommended  by 
the  German  authors. 

Some  objections  have  been  raised  to  the  use  of  these  drugs  on 
the  score  that  they  increase  the  flow  of  urine,  thus  aggravating  the 
local  irritabihty.  The  fact  is,  however,  that  the  presence  of  fairly 
normal  urine  in  the  bladder  in  moderate  quantity  seems  to  relieve 
rather  than  increase  its  irritable  condition. 

The  local  treatment  may  be  as  follows :  A  cupful  of  warm  hop- 
tea,  containing  from  twenty  to  forty  drops  of  laudanum,  may  be 
injected  into  the  rectum.  Suppositories  containing  opium  may  often 
be  used  with  benefit.  With  the  opium  or  morphine  in  the  supposi- 
tories may  be  combined  belladonna,  atropine,  or  hyoscyamus.  Mor- 
phine in  the  form  of  Magendie's  solution  may  be  injected  directly 
into  the  bladder.  There  seems  to  be  no  especial  advantage  in  this 
mode  of  administering  anodynes,  hypodermic  injections  of  the  drug 
acting  as  well,  if  not  better.  Emulsions,  decoctions,  and  infusions 
of  cannabis  Indica,  hyoscyamus,  belladonna,  and  other  like  drugs 
may  be  used  by  the  mouth,  as  the  case  may  require. 

Good  effects  have  followed  the  use  of  rectal  injections  containing 
chloral  hydrate  (grains  15  to  water  ^i  or  sij).  It  may  also  be  given 
by  the  mouth,  but  does  not  usually  act  so  quickly  or  have  such  a 
direct  local  effect. 


662  DISEASES  OF   WOMEN. 

Tlie  injection  into  the  bladder  of  a  solution  containing  morphine, 
followed  by  canterizution  of  the  mucous  membrane,  is  highly  spoken 
of  by  l>nixton  Jlicks.  He  claims  in  this  way  to  deaden  the  reflex 
iriitability  of  the  membrane. 

I  must  insist  on  this — that  opium  shall  be  used  in  such  cases  with 
great  care,  and  never  continued  long.  If  this  rule  is  neglected,  it 
will  lead  many  nervous  padents  to  contract  the  opium  habit,  which 
disease  is  worse  than  irritable  bladder. 

Debout  recommends  the  use  of  bromide  of  potassium  by  the 
mouth,  and  also  in  suppository,  combining  with  it  in  the  latter  tinct- 
ure of  opium  and  belladonna.  I  prefer  hydrobromic  acid  to  the 
bromide  of  potassium. 

When  the  trouble  is  due  to  masturbation,  moral  and  mental  in- 
fluences must  be  brought  to  bear,  as  well  as  medication  and  regula- 
tion of  diet  and  habits.  In  these  cases  the  bromides  will  be  of  serv- 
ice. 

If  all  other  treatment  fails  to  accomplish  the  desired  result,  resort 
should  be  had  to  mechanical  means,  viz.,  the  rapid  and  forcible  dila- 
tation of  the  urethra.  Some  authors,  indeed,  think  so  highly  of  this 
method  that  they  boldly  assert  that  time  spent  in  medication  is  tima 
lost.  Astonishing  and  very  gratifying  results  have  certainly  followed 
its  use  in  a  number  of  cases.  Hewetson  i*eports  in  the  "' Lancet" 
(page  4,  vol.  xii,  1875)  that  in  this  manner  he  cured  a  case  of  cysto- 
spasm  of  fifteen  years'  duration.  This  procedure  is  spoken  of  in  the 
highest  terms  by  Teale  ("Lancet,"  page  27,  vol.  xi,  1875),  as  also  by 
Sj)iegleberg,  Tillanx,  and  others.  In  the  cases  where  this  treatment 
gives  relief,  I  believe  that  there  is  some  inflammatory  condition 
present,  or  at  least  something  more  than  a  neurosis. 

When  due  to  malaria,  the  treatment  is  usually  simple  and  satis- 
factory. Quinine  in  full  doses,  as  recommended  l)y  Briclieleau 
("  Arch.  gen.  de  med."),  for  one  day,  and  then  in  small  doses  before 
meals  for  a  week,  will  usually  cut  the  trouble  short,  and  prevent  its 
return.  The  digestive  organs  require  attention  when  they  are  out 
of  order,  as  they  usually  are. 

If  due  to  hysteria,  the  Original  disease  should  be  treated,  not, 
however,  neglecting  the  local  trouble.  When  accompanying  acute 
or  chronic  systemic  diseases,  it  is  only  relieved  when  the  original 
disease  is  cured,  altliough  in  the  mean  time  the  annoyance  may  be 
greatly  alleviated  by  the  treatment  already  recommended. 


FUNCTIONAL  DISEASES  OF  THE   BLADDER.  663 


UXUSTRATIVE    CASES    OF    FUNCTIONAL    DISEASES    OF    THE    BLADDER,    IN 
WHICH    THERE    IS    NO    RECOGNIZABLE    ORGANIC    LESION. 

Neuralgia  of  the  "DTrethra  and  Neck  of  the  Bladder. — A  married 
lady,  who  had  never  been  pregnant,  was  iirst  seen  when  she  was 
twenty-six  years  of  age ;  she  had  then  been  three  years  married.  She 
was  well  developed,  and,  although  of  a  marked  nervous  tempera- 
ment, had  always  enjoyed  good  health.  From  puberty  onward  she 
had  suffered  pain  at  her  menstrual  periods,  but  not  of  severe  charac- 
ter. When  she  was  twenty-four  years  old  she  was  chilled  while  rid- 
ing a  long  distance  on  a  cold  day,  which  was  followed  by  frequent 
and  painful  urination.  This  was  somewhat  relieved  by  rest  and 
diuretics.  From  that  time  she  was  subject  to  violent  attacks  of  spas- 
modic pain  in  the  urethra  and  bladder.  The  pain  was  of  a  sharp, 
lancinating  character,  generally  coming  on  before  and  after  her  men- 
strual period ;  it  was,  however,  brought  on  at  any  time  by  nervous 
excitement  or  great  fatigue.  During  the  pain  there  was  some  diffi- 
culty in  urinating,  but  the  pain  was  neither  relieved  nor  increased 
by  the  act.  The  duration  of  the  pain  varied,  but  usually  did  not  last 
more  than  twenty-four  hours.  At  times  she  became  almost  frantic, 
so  great  was  the  suffering.  Large  doses  of  opium  would  relieve  her, 
but,  as  it  caused  very  distressing  after-effects,  she  avoided  taking  it, 
except  when  the  attacks  were  exceptionally  severe  and  prolonged. 
When  she  first  came  under  my  care  she  had  a  flexion  of  the  uterus, 
with  slight  general  tenderness  of  the  pelvic  organs,  which  accounted 
for  her  mild  dysmenorrhoea,  and  I  presumed  that  that  might  be  the 
cause  of  the  neuralgic  pains  in  the  bladder  and  urethra.  She  was 
treated  for  the  uterine  affection,  and  obtained  complete  relief  from 
the  painful  menstruation  and  tenderness  of  the  pelvic  organs  gener- 
ally, but  no  relief  was  obtained  from  the  periodic  attacks  of  pain 
in  the  urethra  and  bladder.  She  acknowledged  that  it  was  not  quite 
so  severe  at  her  menstrual  periods,  but  was  "  bad  enough  in  all  con- 
science," as  she  expressed  it. 

Careful  and  repeated  examinations  of  the  urine  were  made  when 
she  had  pain,  and  when  she  was  free  from  it,  but  no  trace  of  any 
renal,  vesical,  or  urethral  disease  was  obtained.  The  urethra  and 
neck  of  the  bladder  were  examined  with  the  endoscope  several  times, 
but  were  found  to  be  normal.  Suspecting  that  the  neuralgic  pain — 
for  such  it  apparently  was — might  be  due  to  malaria,  she  was  given 
fifteen  grains  of  quinine  within  a  period  of  eight  hours,  followed 
by  Fowler's  solution  of  arsenic  in  doses  of  three  minims  after  each 
meal.     The  arsenic  treatment  was  continued  for  several  weeks,  and 


664  DISEASES  OF  WOMEN. 

gave  her  some  relief,  the  attacks  being  less  violent,  but  still  she 
suffered  greatly. 

Moderate  dilatation  of  the  urethra  was  then  practiced.  This  ag- 
gravated the  trouble.  Several  different  remedial  agents,  inchidiiig 
opium,  hot  water,  aconite,  infusion  of  hops  and  belladonna,  were  in- 
jected into  the  bladder,  but  none  of  them  gave  any  relief.  The 
citrate  of  iron  and  quinia  in  tive-grain-doses  was  then  prescribed  t(» 
be  taken  before  meals,  and  Parrish's  compound  sirup  of  the  phos- 
phates in  drachm  doses  to  be  taken  after  meals.  When  the  pain 
came  on  she  was  directed  to  take  every  three  hours  a  drachm  of 
camphor- water  containing  eight  grains  of  muiiate  of  ammonia,  and 
to  use  a  vaginal  douche  of  hot  water.  This  treatment  usually  re- 
sulted in  mitigating  the  pain,  but  did  not  completely  abolish  it. 
Thirty  minims  of  the  compound  spirits  of  ether  and  five  minims  of 
the  tincture  of  cannabis  Indica  every  four  hours  were  substituted  for 
the  camphor- water  and  muriate  of  ammonia  and  M'ith  good  effect. 
Under  this  treatment  her  attacks  were  far  less  frequent,  and  the  re- 
lief from  pain  was  prompt.  She  was  so  much  pleased  with  her  im- 
provement that  she  took  a  trip  through  the  West  and  retunied 
quite  well,  and  has  remained  so  for  the  past  eiglit  years.  More  re- 
cently I  have  had  a  case  which  resembled  this  one  in  many  respects, 
particularly  as  regards  the  character  of  the  pain  and  its  causation, 
in  which  a  four-per-cent  solution  of  muriate  of  cocaine  instilled  into 
the  urethra  and  bladder  gave  relief. 

A  Peculiar  Form  of  Neuralgia  not  yet  described,  excited  by  a 
Desire  to  Pass  Water  and  by  Micturition.  (By  Dr.  Putegnat,  of 
Lmieville.  (Gaz.  Hebdom  de  med.  et  chirurg.,  April  15,  18G4.) — 
The  following  two  cases,  out  of  six  published  by  the  author,  will 
give  an  idea  of  this  peculiar  neuralgia,  which  consists  on  the  one 
hand,  in  a  special  sensation  in  the  bladder,  and  on  the  other,  in 
symptoms  of  a  neurosis  of  the  ulnar  nerve. 

M.  X.,  aged  fifty,  with  chestnut  hair,  of  a  ner\'ous  and  san- 
guine temperament,  very  abstemious,  in  affluent  circumstances,  lead- 
ing a  very  active  life,  occupying  very  iiealth}'  apartments,  free  from 
all  diathesis,  except  a  slight  rheumatic  affection,  liable  to  coryza  in 
cold,  damp  weatlier,  has  never  had  any  other  nervous  complaint  be- 
yond headache  and  occasional  gastralgia  after  eating  dressed  salads 
or  raw  fruit. 

From  time  to  time,  at  varying  intervals  of  weeks,  months,  and 
even  years,  without  any  apparent  physical  or  moral  cause,  in  all 
electric,  barometric,  and  thermometric  conditions  of  the  atmosphere, 
as  soon  as  his  bladder  is  full,  and  he  has  a  strong  desire  to  pass 


FUNCTIONAL  DISEASES   OF  THE   BLADDER.  605 

water,  he  feels  along  the  urinary  passages,  especially  in  the  pcrinaeiun 
a  peculiar  sensation  of  numbness,  not  very  painful,  but  acute,  burn- 
ing, lancinating,  and  unpleasant  from  the  accompanying  sense  of 
prostration.  This  strange  sensation  next  affects  the  slioulders, 
conies  down  both  arms,  along  the  course  of  the  ulnar  nerve  only, 
and  gives  rise  in  the  forearm,  the  little  and  the  ring  fingers,  to  the 
same  sensation  as  when  the  ulnar  nerve  is  strongly  compressed  at 
the  elbow.  The  pain  is  more  acute  on  the  left  than  on  the  right 
side,  lasts  about  twenty  or  thirty  seconds,  and  after  diminishing 
gradually,  disappears  without  leaving  any  trace  behind  it. 

M.  X.,  of  Luneville ;  living  in  healthy  rooms ;  very  active, 
easily  moved  and  excited  ;  subject  to  headaches  and  to  rheumatic 
pains ;  free  from  any  diathesis ;  very  abstemious  ;  complains,  for 
several  successive  days,  but  at  irregular  intervals,  and  without  any 
known  cause,  of  a  strange  sensation  along  the  outer  border  of  the 
left  forearm,  on  the  inner  side  of  the  thumb,  and  the  outer  surface 
of  the  index-finger  especially.  This  sensation  he  compares  to  the 
one  produced  in  the  last  two  fingers  of  the  hand  by  compression  of 
the  ulnar  nerve  at  the  elbow. 

The  painful  sensation  only  comes  on  whenever  he  has  a  strong 
desire  to  pass  water,  persists  during  micturition,  and  ceases  com- 
pletely immediately  afterward. 

On  analyzing  the  six  cases  of  the  author,  we  find  four  of  them 
to  have  occurred  in  females.  The  mean  age  of  the  patients  is  forty- 
six  ;  the  oldest  being  fifty-two,  and  the  youngest  thirty-six  years 
old.  They  are  all  in  easy  circumstances ;  five  occupy  healthy  apart- 
ments, the  sixth  only  living  in  damp  rooms  on  the  ground  floor. 
Three  patients  have  had  gastralgia ;  the  fourth  sciatica,  and  great 
troubles  have  shaken  his  nervous  system ;  the  fifth  is  subject  to  vio- 
lent headaches ;  and  the  sixth,  a  female,  seems  to  have  epileptiform 
seizures,  and  has  a  double  neuralgia.  From  the  above,  then,  it  may 
be  concluded  that  neuralgia  and  great  nervous  excitability  are  pre- 
disposing causes  of  this  strange  neuralgic  affection. 

In  one  of  the  four  female  patients  the  catamenia  had  ceased  ;  in 
three  they  had  not,  and  in  two  of  these  the  neuralgia  showed  itself 
before  and  during  the  menstrual  periods.  Uterine  congestion  seems 
then  to  be  a  predisposing  cause  also. 

Four  of  the  six  patients  had  had  rheumatic  pains  ;  but  the  other 
two  having  never  suffered  from  such  pains,  this  can  not  be  consid- 
ered as  the  exciting  cause  of  the  neuralgic  affection. 

The  desire  to  pass  water,  and  especially  the  act  of  micturition, 
brings  on  the  sensation,  wliich  only  appears  at  those  stated  times, 


60(5  DISEASES  OF   WOMEN. 

and  it  reaches  its  maximum  intensity  at  the  beginning  of  the  mic- 
turition. It  has  all  the  characters  of  neuralgia,  and  can  even  aggra- 
vate, as  in  one  case,  an  already  pre-existing  neuralgia — that  of  the 
median  nerve. 

As  to  tlie  precise  seat  of  the  sensations,  we  find  them  affecting  the 
four  extremities  of  one  patient,  but  the  upper  limbs  only  of  the  re- 
maining five.  In  three  cases  they  simulate  to  pei-fection  neuralgia 
of  the  ulnar ;  and  in  two  they  are  felt  in  the  tips  of  all  the  fingers. 
In  one  case  tliey  coincide  with  and  intensify  pains  in  the  course  of 
the  median  ;  and  lastly,  as  in  the  first  case  we  have  given  above 
they  are  felt  in  the  distribution  of  the  left  radial  nerve. 

The  first  patient  complains  of  pain  in  both  shouldei'S,  especially 
the  left ;  the  fourth,  of  pain  in  both  arms  and  hands,  but  chiefly  in 
both  breasts,  and  in  the  left  breast  more  than  the  right ;  the  sixth, 
again,  of  pain  in  both  forearms  and  hands,  but  more  marked  on  tlie 
left  side.  Hence,  the  left  side  of  the  body  would  seem  to  be  either 
the  only  one  affected,  or  the  one  most  affected. 

Ihe  patients  always  distinguished  clearly  the  special  painful  sen- 
sations felt  in  the  urinary  passages  from  the  normal  sensations  due 
to  a  distention  of  the  bladder  and  the  subsequent  desire  to  pass 
water. 

Retention  of  Urine  Due  to  Hysteria. — A  single  lady,  thirty-one 
years  of  age,  of  delicate  organization  and  pronounced  nervous  tem- 
perament, yet  very  quiet  and  self  possessed  in  manner,  suffered  for 
some  time  Math  difiiculty  of  urination.  At  times  she  could  urinate 
very  well,  at  others  she  was  obliged  to  try  repeatedly  before  she 
succeeded.  She  was  a  lady  of  high  culture  and  liberal  education, 
but  was  not  interestedly  occupied,  and  hence  she  had  much  time  for 
introspection. 

She  called  her  physician  who  prescribed  remedies,  but  iinding 
that  they  did  not  give  her  relief,  made  an  examination  of  the  pelvic 
organs  but  could  find  no  cause  for  her  inability  to  urinate  with  facil- 
ity. 

Soon  after  she  was  taken  with  com{)lete  retention  which  was  re- 
lieved by  the  catheter.  This  continued  for  weeks,  requiiing  the 
doctor  to  visit  her  three  times  a  day,  and  occasionally  at  night,  to 
pass  the  catheter.  For  some  reason  which  was  not  very  evident 
and  could  hardly  be  due  to  weakness  or  suffering,  she  remained  in 
bed  most  of  the  period  duiing  which  the  catheter  was  used.  Be 
coming  weary  of  such  close  attention,  the  doctor  tried  letting  her 
wait,  to  see  if  a  full  distention  of  the  bladder  would  have  any  good 
effect.     This  caused  her  so  much  pain  that  the  doctor  felt  somewhat 


FUNCTIONAL   DISEASES   OF   THE    BLADDER.  G67 

mortified  at  his  want  of  feeling-  in  permitting  her  to  suffer.  Dur- 
ing this  time  he  had  tried  a  number  of  remedies,  but  without 
effect.  At  this  stage  of  the  history  I  was  called  in  consultation ; 
I  could  Und  no  evidence  of  any  organic  disease,  local  or  general. 
The  urine  was  found  ujjon  examination  to  be  normal.  I  suggested 
to  the  attending  physician  that  the  trouble  was  hysteria,  but  he  as- 
sured me  that  she  was  singularly  free  from  all  evidences  of  that 
affection.  Indeed,  he  had  found  her  a  remarkably  calm  and  sensible 
lady,  and  \Q.r^  free  from  nervousness  of  every  kind.  The  impression 
that  I  received  was  that  there  was  a  very  decided  hysterical  element 
in  the  case,  and  I  advised  full  doses  of  bromide  of  potassium  and  a 
sitz-bath  when  she  desired  to  urinate.  I  also  recommended  that  she 
should  go  to  Saratoga,  and  drink  Hathorn  water.  She  did  this, 
and  the  water  gave  her  diarrhoea,  and  her  retention  was  immedi- 
ately relieved. 

Frequent  TTrination  Due  to  Hysteria. — A  lady  twenty-three  years 
of  age,  in  very  good  general  health,  and  living  in  very  easy  circum- 
stances, had  some  disappointment  which  caused  her  much  distress. 
She  had  faintings  of  a  mild  character  which  alarmed  her  mother 
and  called  forth  much  sympathy.  About  this  time  she  began  to 
suffer  from  frequent  urination.  This  did  not  yield  to  the  treatment 
employed  by  the  family  physician,  and  she  was  brought  to  my  office 
for  advice.  Her  health  was  at  times  excellent,  but  she  was  greatly 
annoyed  by  this  frequent  urination.  The  urine  was  nonnal  except 
at  times  when  it  was  of  a  very  light  color.  She  could  sleep  all  night 
without  being  disturbed  by  a  desire  to  urinate.  If  by  chance  she 
did  not  go  to  sleep  immediately  on  retiring  she  was  obliged  to  urin- 
ate every  few  minutes,  and  if  she  was  awakened  in  the  night  she 
had  to  urinate  many  times  before  she  could  sleej)  again. 

Any  little  mental  excitement,  such  as  going  to  church  or  to  the 
theatre,  would  bring  on  the  trouble,  so  tliat  she  had  to  give  up  all 
public  duties  and  pleasures.  Systematic  exercise  and  occupation, 
cold  baths,  bromide  of  sodium,  and  a  full  assurance  on  my  part  that 
she  would  soon  recover,  helped  her  greatly.  She  was  commanded 
in  a  very  decided  way  to  resist  the  inclination  to  such  frequent  urin- 
ation, and  she  obeyed  orders. 

Soon  after  this  her  attention  was  attracted  in  another  and  more 
interesting  direction,  and  she  recovered  completely. 

Frequent  Urination  from  Perverted  Sexual  Function. — A  girl 
nineteen  years  of  age  who  had  a  good  general  organization  and  en- 
joyed good  health  up  to  puberty  at  fourteen,  sought  advice  regard- 
ing impatience  of  her  bladder.     She  was  obliged  to  return  home 


668  DISEASES   OF   WOMEN. 

from  boarding-scliool  because  she  luid  to  ui-inate  so  often  that  she 
could  not  attend  to  her  studies  and  recitations.  Her  general  nutri- 
tion was  good,  she  menstruated  regularly,  freely,  and  without  acute 
pain.  Her  nervous  system  was  depressed.  She  was  sometimes  lan- 
guid, low  spirited  and  fretful,  at  other  times  she  was  bright  and  dis- 
posed to  be  cheerful.  Her  manner  was  rather  timid  and  ex'cited. 
Her  hands  were  clammy,  and  her  eyes  dull,  and  had  dark  streaks 
under  them.  Her  chief  symptom  was  the  frequent  urination  which 
parsisted  but  was  much  worse  at  times  than  at  others.  Occa- 
sionally she  would  pass  the  night  without  getting  up  more  than 
once  or  twice,  but  during  the  day  she  was  often  obliged  to  urinate 
every  half-hour.  There  was  very  little  pain  except  occasionally  a 
little  smarting  at  the  meatus.  She  complained  of  heat  and  burning 
about  the  vulva  and  occasional  aching  in  the  region  of  the  ovaries. 
She  was  easily  fatigued  and  had  backache,  especially  on  standing  and 
walking— leucorrhoea  ti'oubled  her  only  at  times. 

I  suspected  at  first  that  she  had  either  cystic  and  urethral  con- 
gestion, or  else  hysteria  giving  rise  to  excessive  renal  secretion  of 
limpid  urine,  but  an  examination  of  the  quantity  and  composition  of 
the  urine  proved  the  contrary.  She  was  put  in  charge  of  a  very 
competent  nurse  who  was  directed  to  find  out  the  habits  of  the 
patient. 

The  report  of  the  attendant  was  that  she  had  begun  to  indulge  in 
masturbation  soon  after  puberty,  and  that  the  hal)it  had  gradually 
grown  upon  her.  Her  nurse  surprised  her  by  relliug  her  the  cause 
of  her  sufiering,  and  readily  gained  her  consent  to  make  all  due 
efforts  to  recover  her  self-control.  By  care,  occupation,  and  exercise 
out-of-doors,  and  the  moral  control  of  her  nurse,  she  began  to  im- 
prove. Bromide  of  sodium  was  given  when  she  was  very  restless 
and  irritable,  but  no  other  medication,  except  the  free  use  of 
bathing. 

In  about  two  months  the  frequent  urination  had  disappeared,  al- 
though she  would  occasionally  have  a  day  or  a  night  when  she  suf- 
fered in  that  way  a  little.  She  now  has  two  children,  and  enjoys 
life  very  well,  being  free  from  her  former  symptoms  and  no  doubt 
cured  of  her  former  habit. 

Frequent  and  Difficult  Urination  from  Sexual  Continence. — The 
patient,  a  strong  and  active  lady  in  good  circumstances,  was  married 
at  twenty-one  years  of  age,  and  had  her  first  bal)y  before  she  was 
twenty-two.  She  nursed  the  child  for  eighteen  months.  Her 
menses  came  on  when  the  child  was  one  year  old.  About  three 
years  after  her  marriage,  her  husband,  a  strong,  \ngorous  man,  died 


FUNCTIONAL   DISEASES   OF   THE   BLADDER.  QCj'J 

of  pneumonia.  Several  months  after  the  loss  of  her  husband  she 
began  to  sutler  at  times  from  frequent  urination,  and  also  had  some 
difficulty  in  voiding  the  urine,  requiring  voluntary  efforts.  Tliese 
attacks  would  pass  oif,  and  she  would  be  comfortable  for  days, 
when  th'j  same  irritation  of  the  bladder  would  return.  She  was 
always  made  worse  by  excitement,  often  being  kept  awake  nearly 
all  night  after  spending  the  evening  in  company. 

Her  symptoms  became  so  troublesome  that  she  sought  advice  of 
a  physician,  who  treated  her  for  cystitis  by  giving  medicines  of  va- 
rious kinds.  When  she  tirst  came  under  my  observation  I  found 
her  in  perfect  health  in  every  way.  The  urine  was  normal,  and 
caused  no  pain  when  she  passed  it.  I  was  easily  able  to  exclude  all 
diseases  except  deranged  innervation  from  a  possible  malarial  influ- 
ence. The  periodical  character  of  the  attacks  favored  this  view  of 
the  case,  but  the  use  of  the  anti-malarial  remedies  gave  no  relief.  I 
then  ordered  her  to  take  more  active  exercise  and  a  limited  quantitj^ 
of  plain  food,  to  bathe  frequently,  and  to  avoid  excitement  as 
far  as  possible.  Bromide  of  sodium  was  also  given  when  her 
suffering  was  most  severe.  She  improved  on  this  treatment  for  a 
time,  in  fact  she  became  so  much  better  that  I  lost  sight  of  her  for 
nearly  a  year.  She  returned  to  say  that  her  former  symptoms  had 
returned,  and  were  about  as  troublesome  as  before.  The  same  treat- 
ment was  employed  but  did  not  help  her  very  much.  She  was 
now  rather  nervous  and  restless,  and  disposed  to  be  emotional. 

Three  months  afterward  she  was  married,  and  left  the  city  on 
an  extended  wedding-tour.  Upon  her  return  she  reported  herseK 
as  perfectly  well. 

A  Case  of  Malarial  Irritation  of  the  Bladder  in  the  Female.  (By 
Henry  K.  Leake,  M.  D.,  Dallas,  Texas.  Abstract  of  a  paper  read 
before  tlie  Texas  State  Medical  Association.)  I  desire  to  record 
an  observation,  which  I  have  recently  made,  exemplifying  the 
effect  that  the  malarial  poison  may  exert  upon  the  female  blad- 
der ;  an  observation  which  may  appear  commonplace  since,  as  is 
well  known,  it  has  not  escaped  mention  by  Prof.  Skene  in  his  excel- 
lent work  on  the  "■  Diseases  of  the  Bladder  and  Urethra  in  the 
Feuiale"  as  well  as  by  other  authors  of  equal  or  less  prominence, 
who  have  attended  to  the  same  subject. 

Nevertheless,  considering  the  mere  allusions  by  these  writers  to 
irritation  of  the  bladder  in  women,  which  may  be  caused  by  the 
presence  of  malaria  in  the  system,  on  account,  doubtless,  of  the  rare 
occurrence  of  this  affection,  it  may  be  questioned  whether  the  latter 
has  been  sufficiently  individualized  as  a  distinct  and  independent 


GTO  DISEASES  OF   WOMEN. 

malady,  deserving  especial  prominence  in  the  nosology  of  diseases  of 
the  bladder,  which  seriously  disturb  the  functions  of  this  sensitive 
viscus.  There  is  the  additional  reason,  also,  for  reporting  the  ex- 
perience which  I  have  had  of  this  peculiar  and  interesting  disorder, 
in  the  fact  that  much  obscm'ity  yet  surrounds  the  entire  subject  of 
disturbance  of  the  functions  of  this  organ  in  the  female,  the  integrity 
of  which  is  so  vital  to  the  comfort,  happiness,  and  safety  of  the  in- 
dividual. 

Moreover,  such  conditions  often  tax  the  diagnostic  acumen  of 
the  physician  to  the  utmost,  and  even  when  by  the  exclusive  method, 
rigorously  employed,  many  causes  of  ii'ritation  of  the  bladder  may 
be  eliminated  from  the  problem  in  hand,  there  will  yet  remain  in 
particular  cases,  other  causes  which  may  elude  discovery,  thus  ob- 
scuring the  pathogeny  and  defeating  every  measure  of  treatment 
which  is  attempted. 

About  March  1st,  of  the  present  year,  a  lady,  whose  health  has 
been  uninterruptedly  good,  thirty-seven  years  of  age,  the  mother  of 
six  children,  the  last  of  which  being  an  infant  of  four  months,  ap- 
plied to  me  for  treatment  for  what  she  considered  the  ailment  to 
be,  incontinence  of  urine.  She  stated  that  the  condition  had  come 
on  gradually,  at  the  first  amounting  to  a  mere  frequency  of  urina- 
tion during  the  day,  without  any  attendant  pain  or  other  symptom 
which  attracted  her  attention.  This  frequency  had  increased,  how- 
ever, to  such  an  extent  as  to  seriously  embarrass  her  in  the  perform- 
ance of  domestic  duties,  and  prevent  her  from  visiting  friends,  or 
doing  necessary  shopping.  Moreover,  she  soon  became  troubled  at 
night,  often  rising  six  or,  perhaps,  a  dozen  times,  in  obedience  to 
the  urgent  calls  for  micturition.  The  amount  of  urine  passed  at 
each  discharge  was  not  large,  but  exceeded  in  quantity  that  ordi- 
narily retained  in  cases  of  acute  cystitis,  which  the  affection  in 
many  respects  closely  resembled. 

There  were  no  deposits  in  the  urine  worth  noting.  It  appeared 
to  be  somewhat  higher  colored  than  noi-mal.  There  was  also  a 
superabundance  of  nmcus,  in  the  form  of  large  tiocculi,  but  no  pus 
or  blood. 

As  the  case  progressed,  the  desire  to  evacute  the  liladder  was 
preceded  by  a  sharp  twinge  of  pain,  which  the  patient  averred  was 
"  low  down  at  the  very  neck  of  the  bladder,"  but  which  was  imme- 
diately relieved  on  emptying  the  viscus.  There  was  no  tenderness 
at  any  point  except  a  slight  pain  experienced  when  the  neck  of  the 
bladder  was  firmly  pressed  toward  the  pelvis. 

The  frequency  of  micturition  increased  to  almost  constant  drib- 


FUNCTIONAL  DISEASES   OF  THE  BLADDER.  671 

Tjlinp^  from  the  bladder,  both  daily  and  nocturnally  the  cloud  of 
iiiuciis  in  the  urine  was  much  augmented,  and  while  the  color  ap- 
peared to  remain  unchanged,  there  was  evidently  a  large  excretion  of 
solid  matter  composed  probably  of  phosphates. 

The  uneasiness  elicited  at  the  neck  of  the  bladder  by  pressure  on 
this  part  soon  changed  to  actual  soreness.  At  the  end  of  the  second 
week  the  case  had  passed  into  one  of  apparently  serious  import,  and 
was  operating  with  telling  effect  on  the  vitality  and  mental  equipoise 
of  the  patient. 

The  tripod  of  treatment,  namely,  rest,  opium,  and  alkalies,  upon 
which  Van  Buren  and  Keyes  cogently  protest  the  successful  manage- 
ment of  cystitis  rest,  was  relied  on  to  relieve  what  I  now  feared 
was  a  case  of  this  distressing  disease,  the  cause  of  which  I  could 
not  then  determine.  The  constitutional  effect  of  belladonna  was 
evoked  also  to  mitigate  the  symptoms,  and  finally  hot-water  vaginal 
injections  were  employed  for  their  well-known  analgesic  and  anti- 
phlogistic effects  upon  the  pelvic  viscera. 

Such  measures  gave  only  temporary  relief,  the  features  of  the 
case  resuming  their  original  character  whenever  the  effect  of  medi- 
cation— which  was  occasionally  suspended  to  ascertain  the  status  quo 
of  the  disease — had  passed  off. 

At  the  beginning  of  the  third  week  from  the  first  appearance  of 
the  symptoms,  the  patient  complained  of  slight  chilliness  toward 
evening,  and  it  was  observed  that  this  was  followed  by  fever,  the 
thermometer  in  the  mouth  registering  101.°  These  symptoms  were 
interpreted  to  indicate  the  constitutional  expression  of  the  local  in- 
flammation existing  in  the  bladder.  Hence,  no  special  attention  was 
directed  toward  them.  The  chilliness  was  repeated,  however,  on  the 
third  evening,  and  on  the  fourth  day  at  the  same  hour  reappeared 
as  the  prodrome  of  a  marked  rigor,  followed  by  an  abrupt  rise  of 
temperature  of  103°  succeeded  by  sweating  and  a  return  to  the 
normal  temperature  in  about  four  hours,  thus  clearly  demonstrating 
a  well-defined  periodicity  of  the  febrile  movement. 

Suspicion  being  now  aroused  as  to  the  essential  nature  of  the 
case,  the  patient  was  promptly  placed  on  ten-grain  doses  of  the  sul- 
phate of  quinine,  to  be  taken  every  four  hours  with  mercurial  and 
saline  purgatives,  the  latter  being  indicated  by  the  appearance  of  the 
tongue  and  the  confined  state  of  the  bowels,  which  was  due  not  alto- 
gether to  the  opium  administered,  since  this  physical  modifier  had 
been  exhibited  both  freely  and  simultaneously. 

The  substitution  of  the  quinine  for  the  treatment  previously 
pursued,  like  the  fabled  wand  of  the  magician,  broke  the  spell  of 


672  DISEASES   OF    WOMEN. 

encliantment,  wliicli,  by  its  subtle  and  potent  influence  bad  beld 
tbe  patient  \vitb  relentless  grasp  for  tbree  weeks  and  bad  trans- 
formed a  bopeful  and  contented  disposition  into  one  of  nielancboly 
and  apprebension. 

At  tbe  end  of  four  days  from  tbe  administration  of  tbe  first 
dose  of  quinine  tbe  patient  was  virtually  convalescent.  During  tbis 
period  no  opiate  was  employed  nor  any  otber  medicine  but  quinine 
taken,  save  an  occasional  dose  of  neutral  mixture,  cbiefly  for  its  su- 
dorific effect.  Nevertbeless  tbe  irritation  of  tbe  bladder  did  not  re- 
turn, and  tbe  close  of  tbe  week  found  tbe  patient,  altbougb  deblH- 
tated  by  tbe  trying  ordeal  tbrougb  wbicb  sbe  bad  passed,  enabled 
to  resume  ber  accustomed  duties. 

Periodical  Attacks  of  Frequent  and  Painful  Urination  and  Vesical 
Tenesmus  caused  by  Malaria. — About  two  years  ago  a  patient  came  to 
my  college  clinic  complaining  as  follows  :  In  tbe  afternoon  of  eacb 
day  sbe  experienced  a  sense  of  beat  and  burning  in  tbe  bladder  and 
uretbra,  witb  a  frequent  and  irresistible  desire  to  urinate.  Evacua- 
tion of  tbe  bladder,  attended  witb  a  great  deal  of  smarting  and  pain 
in  tbe  uretbra,  did  not  give  complete  relief  but  left  some  vesical 
tenesmus  wbicb  increased  in  severity  as  tbe  bladder  became  dis- 
tended. Tbese  symptoms  persisted  during  tbe  niglit  and  kept  ber 
awake,  but  toward  morning  ber  sufferings  entirely  left  ber,  and  sbe 
became  quite  comfortable  until  tbe  next  afternoon.  Tbis  condition 
bad  existed  for  nearly  two  montbs,  and  accordingly  ber  digestion  be- 
came impaired  and  ber  strengtb  diminisbed.  Tbis  was  attributed 
by  ber  to  tbe  want  of  sleep,  and  no  doul)t  in  part  was  due  to  tbis 
cause.  Tbe  urine  was  examined,  and  found  to  be  normal  except  tbat 
it  contained  a  sligbt  excess  of  pbospbates.  Sbe  was  carefully  exam- 
ined, and  no  evidence  of  organic  disease  was  found.  Wbile  sbe  al- 
ways enjoyed  full  bealtb  and  bad  been  a  vigorous  woman,  s^be  bad  bad 
an  attack  of  malarial  fever  about  six  montbs  before  I  saw  ber,  and 
about  tbe  time  tbis  bladder  trouble  came  on  sbe  said  sbe  bad  symp- 
toms of  ber  former  ague.  From  tbe  facts  in  ber  bistory  I  ventured 
to  state  to  my  class  tbat  tbis  was  a  functional  derangement  of  tbe 
bladder  and  uretbra  caused  by  malaria,  wbicb  would  promptly  yield 
to  judicious  doses  of  quinine.  I  accordingly  prescribed  twenty 
grains  of  quinine  to  be  taken  between  early  morning  and  noon,  to 
be  followed  by  two-grain  doses  before  meals  witb  four  drops  of 
Fowler's  solution  of  arsenic  after  meals.  Sbe  was  ordered  to  report 
at  tbe  clinic  tbe  following  week.  Sbe  did  so,  and  declared  tbat  sbe 
bad  been  perfectly  well  since  tbe  first  day  sbe  took  tbe  medicine. 
Tbe  quinine  and  arsenic  in  small  doses  were  continued  for  tbree 


FUNCTIONAL   DISEASES   OF   THE   BLADDER.  073 

weelvs,  at  tlic  end  of  wliicli  time  she  reported  herself  as  having  been 
well  and  free  from  all  irritation  of  the  urinary  organs. 

No  change  in  the  character  of  the  urine  could  have  occurred  to 
produce  such  mai-ked  periodicity  in  the  functional  derangement  of 
the  bladder  and  urethra ;  moreover,  the  urine  was  found  to  be  nor- 
mal, and  she  completely  recovered  on  the  use  of  quinine. 

Vesical  Tenesmus  and  Frequent  Urination  due  to  Prolapsus  and  In- 
flammation of  the  Ovaries. — In  prolapsus  of  the  ovaries  and  inflamma- 
tory affections  of  these  organs  irritation  of  the  bladder  often  occurs. 
This  is  illustrated  by  the  following  case : 

A  young  girl  of  twenty-one  was  brought  to  me  suffering  from 
great  distress  in  the  pelvis,  which  was  much  aggravated  by  standing 
or  walking.  Her  suffenng  was  constant,  but  was  tolerable  when  she 
remained  in  the  recumbent  position.  She  began  to  complain  about 
six  months  before  I  saw  her,  and  about  the  same  time  she  found 
that  she  was  obliged  to  urinate  too  often,  and  that  there  was  an  un- 
easy feeling  in  the  bladder  most  of  the  time,  a  feeling  as  if  the 
bladder  had  not  been  fully  evacuated. 

She  was  much  worse  at  her  menstrual  periods.  Upon  a  thor- 
ough examination  I  found  both  ovaries  prolapsed,  slightly  enlarged, 
and  exceeding  tender.  In  every  other  respect  she  was  perfectly 
well.  In  consultation  with  her  physician,  a  course  of  treatment  for 
the  ovarian  disease  was  decided  upon.  This  was  fully  and  faithfully 
tried  for  over  one  year,  but  at  the  end  of  that  time  she  was  worse. 

She  was  then  quite  impatient,  being  very  nervous  and  irritable 
from  her  coniinement  and  suifering.  Her  parents  and  friends  were 
quite  weary  of  seeing  her  suffer.  Her  bladder  irritation  was  no 
better ;  in  fact  it  was  a  great  source  of  suffering.  She  could  not 
urinate  without  getting  uj),  and  the  erect  position  increased  her 
ovarian  pain.  The  ovaries  were  still  prolapsed  and  just  as  tender, 
in  fact,  more  so  than  they  had  been. 

The  complete  failure  of  treatment  so  far  indicated  that  removal 
of  the  ovaries  was  the  only  thing  that  promised  to  give  her  relief. 
Accordingly  the  ovaries  were  removed,  and  she  made  a  rapid  recov- 
ery from  the  operation  and  was  completely  relieved  not  only  from 
her  ovarian  pain  but  also  from  the  frequent  urination  and  vesical 
tenesmus. 

It  should  be  stated  that  at  no  time  was  there  any  evidence  of 
cystitis  found  upon  frequent  and  careful  examinations. 


u 


CHAPTER  XXXYIIL 

FTINCTIONAL    DISEASES    OF    THE    BLADDER  (cONTTNUEd). 

Having  considered  the  vesical  derangements  in  which  there  is 
no  recognizable  organic  lesion,  and  which  may  be  local  nem-oses,  or 
may  be  due  to  hysteria,  disorder  of  the  sexual  function,  malarial  or 
ovarian  affections,  I  will  now  invite  attention  to  the  second  class  of 
these  disorders, 

I.  Derangements  of  function  due  to  diseases  of  the  nutritive  and 
nervous  systems,  or  to  abnormal  conditions  of  the  urine  which  re- 
sult therefrom. 

This  class  naturally  subdi^ddes  itself  into : 

1.  Derangements  occurring  in  both  acute  and  chronic  diseases. 

2.  Derangements  due  to  consequent  abnormal  conditions  of  the 
urine. 

1.  Of  the  derangements  which  occur  in  the  course  of  acute  dis- 
eases, such  as  retention  and  incontinence  of  urine  and  frequent  m-in- 
ation,  nothing  more  than  the  mere  mention  is  necessary.  They 
rarely  require  any  treatment,  except  possibly  in  the  case  of  reten- 
tion, when  catheterization  is  to  be  employed,  and  they  cease  as  soon 
as  the  acute  stage  is  passed.  Those,  however,  which  are  due  to 
chronic  affections  of  the  nutritive  and  nervous  systems  are  more 
permanent,  and  often  tax  the  resources  of  the  physician  to  the 
utmost.     The  two  most  important  are  : 

{a)  Paralysis  of  the  bladder,  and, 

(5)  Incontinence  of  urine. 

{a)  Paralysis  of  the  Bladder. — This  affection  has  also  been  de- 
scribed under  the  names  of  weakness  or  palsy  of  the  bladder,  and 
vesical  atony.  It  occurs  in  two  forms :  First,  from  causes  residing 
in  the  organ  itself ;  second,  from  those  due  to  outside  influences. 
As  affections  in  the  first  form  Avill  be  fully  described  in  another 
place  I  shall  here  simply  mention  them.  They  are :  Fatty  degenera- 
tion and  atropliy  of  the  muscular  walls  of  the  bladder,  a  common 


FUNCTIONAL  DISEASES  OF  THE  BLADDER.  075 

cause  of  paralysis  of  tliis  viscus  in  old  women ;  overstrain  of  the 
muscular  structure  from  prolonged  retention,  voluntary  or  involun- 
tary ;  displacements  and  inflammations  of  neighboring  oi'gans  ati'ect- 
ino-  its  position  or  nutrition ;  and  abdominal  and  pelvic  tumors. 

In  fevers  of  a  serious  type  the  power  of  nerve  conduction  may 
he  either  lost  or  impaired,  and  a  partial  or  total  vesical  paralysis  re- 
sult, with  overdistention  and  dribbling  of  mine. 

The  second  form  is  due  to  influences  acting  from  without  the 
bladder,  and  includes  acute  and  chronic  meningitis;  apoplexies  of 
the  brain  or  spinal  cord  ;  sopor ;  delirium  ;  myelitis  of  the  lower 
part  of  the  spinal  cord  ;  inflanmiation  of  any  kind  primarily  affect- 
ing or  involving  in  its  results  either  the  lumbar  nerves  or  ganglia ; 
endarteritis  deformans  of  the  pelvic  arteries  ;  lumbar  or  renal  ab- 
scesses ;  blows  or  fall  upon  the  loins,  supra-pubic  region,  or  head ; 
shock  or  disease  of  the  vesical  or  lumbar  nerves  from  the  prolonged 
use  of  opium  or  poisoning  by  it,  and  also  shock  due  to  overdisten- 
tion of  the  organ  itself. 

Symptomatology. — Except  in  cases  of  injury  of  the  brain  and 
apoplexies,  the  invasion  of  the  disease  is  usually  very  gradual.  This 
is  especially  the  case  in  the  aged,  and  sometimes,  though  rarely,  in 
young  people.  The  patient  first  observes  that  the  urine  is  expelled 
from  the  bladder  with  less  force  than  usual ;  that  the  act  of  empty- 
ing the  bladder  is  more  slowly  accomplished,  and  that  after  a  time 
the  organ  is  unable  to  expel  its  contents  without  considerable  strain- 
ing and  aid  from  the  abdominal  muscles.  At  a  later  date,  if  the 
disease  goes  on  unchecked,  the  stream  is  less  and  less  forcibly  ejected, 
intermits,  and  the  bladder,  after  much  straining,  is  but  partially 
emptied.     Finally,  partial  or  complete  retention  follows. 

The  female  bladder  seems  to  be  capable  of  more  distention  than 
that  of  the  male.  Lieven,  in  a  case  of  supposed  ovarian  tumor,  re- 
moved by  catheterization  about  nine  pints  of  urine.  The  patient  was 
a  woman  thirty-three  years  of  age.  The  fundus  of  the  bladder 
reached  as  high  as  the  ensiform  cartilage.  I  once  saw  a  case  exactly 
like  this,  except  that  the  bladder  only  reached  to  about  two  inches 
above  the  umbilicus.  More  than  a  gallon  has  been  drawn  off  by 
Hofmeier  and  others. 

A  peculiarly  interesting  experiment  bearing  upon  the  dilatability 
of  the  bladder  was  made  by  Budge.  He  found  that  section  of  the 
lower  part  of  the  spinal  cord,  when  the  bladder  was  considerably 
distended,  allowed  increased  reflex  action  of  the  sphincter,  and 
enormous  distention  then  took  place — even  more  than  could  be  pro- 
duced by  force,  after  death.     This  is  especially  interesting  in  rela- 


070  DISEASES   OF  WOMEN. 

tion  to  vesical  paralysis  and  retention  due  to  injury  or  disease  of  the 
lumbar  portion  of  the  spinal  cord. 

In  some  cases  of  overdistention  the  resistance  of  the  sphincter  is 
overcome  somewhat,  and  a  constant  dribbling  of  urine  takes  })lace. 
It  has  been  called  by  some  authors  incontinentia  parodoxa.  These 
cases  are  liable  to  be  mistaken  for  those  of  pure  incontinence. 

In  rare  cases  rupture  of  the  bladder  may  take  place  ;  more  com- 
monly dilatation  of  the  ureters  and  hydronejDhrosis.  If  the  condi- 
tion of  vesical  distention  be  not  soon  relieved,  vesical  catarrh,  trae 
inflammation,  ulceration,  and  death  take  place.  In  cases  due  to  in- 
jury or  disease  of  the  spinal  cord,  low  down,  there  seems  to  be  a 
paralysis  or  peculiar  condition  of  the  nerves  presiding  over  the  nu- 
trition of  the  vesical  mucous  membrane,  and  destructi\e  changes  are 
not  uncommon. 

Diagnosis. — The  diagnosis  though  easy,  is  sometimes  not  made, 
owine:  to  careless  observation  or  ionorance.  When  called  to  a  case 
where  there  is  supposed  distention  of  the  bladder,  the  abdomen 
should  first  be  examined  to  see  if  there  are  signs  of  a  tumor,  and 
then  a  catheter  should  be  passed  if  that  be  possible,  to  determine 
whether  an  abnormal  amount  of  urine  is  present.  If  this  is  the 
case,  and  the  tumor  gradually  subsides  as  the  urine  flows,  the  diag- 
nosis is  at  once  made.  When,  however,  a  catheter  can  not  be  passed 
into  the  viscus,  fluctuation  should  be  sought  both  through  the  vagina 
and  on  the  surface  of  the  tumor.  If  the  diagnosis  be  still  obscure, 
the  aspirator-needle  should  be  passed  into  the  tumor,  and  its  fluid 
contents  carefully  tested.  The  age  of  the  patient,  the  duration  of 
the  disease,  and  its  time  and  method  of  invasion  will  aid  in  settling 
the  question.  The  trouble  may,  however,  occur  at  almost  any  age, 
and  the  fact  that  a  little  nriue  has  been  passed  at  short  intervals 
will  tend  to  deceive. 

In  the  early  stages  of  the  disease  an  idea  can  be  gained  as  to  its 
progress  by  carefully  noting  the  amount  of  urine  passed  at  each 
micturition,  the  amount  passed  in  twenty-four  hours,  the  length  of 
intervals  between  urination,  the  force  of  the  stream,  whether  the 
bladder  is  fully  or  but  partially  emptied,  and  whether  the  stream 
intermits.  The  urine  should  be  examined  often,  else  cystitis  may 
get  a  tirm  foothold  before  its  existence  is  recognized.  In  drawing 
off  the  urine  for  testing  or  other  purposes,  the  catheter  should  be 
ahsolutel I)  clean. 

Incontinentia  paradoxa  nmst  be  difl[erentiated  from  incontinence 
due  to  mechanical  causes,  such  as  abnormal  urine,  or  the  pressui-e  of 
neighboring  organs  upon  the  bladder. 


i 


FUNCTIONAL  DISEASES  OF  THE  BLADDER.  677 


Prognosis. — If  the  disease  be  uncomplicated  tlie  prognosis  is 
good.  Paralysis  of  the  organ  accom})anying  the  fevers,  d3'seiitery, 
peritonitis,  and  the  like,  usually  disappears  with  the  cure  of  the 
original  disease. 

If  the  paralysis  be  accompanied  by  disease  of  the  bladder-walls, 
or  if  it  occurs  in  weak,  debilitated  constitutious,  or  has  been  of  long 
duration,  or  occurs  in  old  age,  the  prognosis  is  not  good.  A  cure, 
if  eifected  at  all,  will  be  only  after  long  and  tedious  treatment. 

When  due  to  centric  causes  or  to  serious  spinal  disease  or  injury, 
or  when  it  occurs  in  old  people,  or  with  meningitis,  or  with  sys- 
temic trouble,  the  prognosis  is  vei'y  grave  indeed. 

Causation. — Deranged  innervation  due  to  the  central  lesion 
already  mentioned,  either  cerebral  or  spinal,  may  be  regarded  as 
the  principal  cause  of  this  affection.  If  the  paralysis  has  been  of 
long  duration  nutritive  changes  may  occur  in  the  bladdei',  but  as 
these  will  be  discussed  under  the  appropriate  head  I  need  say  noth- 
ing of  them  here. 

Treatment. — In  all  cases  where  there  is  fear  of  vesical  distention, 
the  bladder  should  be  emptied  at  stated  intervals.  ^y  way  of 
helping  the  patient  to  pass  water  herself,  hot  hip-baths  may  be  tried 
and  fomentations  over  the  bladder.  The  sound  of  water  falling 
from  one  vessel  into  another  often  accomplishes  the  same  result.  If 
these  means  do  not  succeed  the  catheter  must  be  used. 

And  here  attention  may  be  called  to  a  very  important  practical 
point  in  connection  with  the  use  of  the  catheter.  When  the  blad- 
der has  become  very  much  distended  it  can  not  be  thoroughly  emp- 
tied unless  pressure  is  made  upon  the  abdominal  walls  ;  if  this  press- 
ure is  made  while  the  catheter  is  in  the  bladder,  and  then  discontin- 
ued, air  will  be  drawn  through  the  catheter  into  the  bladder  and 
decomposition  of  the  urine  will  thus  be  favored. 

Marked  distention  can  usually  be  relieved  by  the  catheter.  In 
some  cases,  however,  the  bladder  rises  up  into  the  abdomen  and 
puts  the  urethra  upon  the  stretch,  thus  changing  the  direction  of  its 
axis  from  the  normal  to  one  from  below  directly  upward,  the  canal 
being  nearly  parallel  to  the  posterior  surface  of  the  pubic  symphy- 
sis. In  these  cases  passing  the  catheter  will  tax  the  skill  somewhat. 
Great  care  must  be  used  to  avoid  injuring  the  urethra. 

In  emptying  a  greatly  distended  bladder  a  binder  should  be  ap- 
plied to  the  abdomen  and  tightened  gradually  as  the  urine  flows.  It 
is  not  safe  to  draw  off  all  the  urine  at  once.  It  is  better  to  take 
away  about  half,  and  then  after  a- time  to  draw  off  more,  until  the 
organ  is  empty.     Syncope  and  even  death,  which  is  said  to  have 


G78  DISEASES  OF  WOMEN. 

occurred  in  these  cases  after  rapid  emptying  of  the  organ,  are  prob- 
ably due  to  the  sudden  removal  of  the  pressure  on  the  abdominal 
organs,  wliich  so  deranges  the  circulation  as  to  cause  these  serious 
results.  Tliu  sudden  removal  of  pressure  from  the  vesical  walls, 
vrhich  that  pressure  rendered  antiemic,  now  allows  intense  conges- 
tion, and  the  vesical  walls  Ijcing  paralyzed  catarrh  and  cystitis  result. 
Therefore,  for  many  reasons,  a  distended  bladder  should  be  emptied 
slowly. 

W^hen,  for  any  rea?on,  a  catlieter  can  not  be  introduced  into  the 
bladder,  hot  hip-baths  should  be  again  tried,  and  opium  given  in  suf- 
ficient amount  to  relieve  pain  and  any  spasmodic  action  that  may 
exist.  If,  after  this,  there  is  failure  to  enter  the  bladder  (and  it  is 
only  in  very  rare  cases  that  this  occurs),  recourse  should  be  had  to 
the  aspirator,  and  after  having  punctured  the  bladder,  the  ui-ine 
should  be  drawn  slowly  and  carefully,  in  the  manner  already  de- 
scribed. 

In  commencing  vesical  paralysis,  and  when  incontinentia  para- 
doxa  exists  or  has  existed,  the  patienr  should  be  taught  to  use  the 
catheter  herself  several  times  daily  until  the  vesical  power  returns. 

It  is  of  the  utm(jst  importance  that  the  catlieter  be  absolutely 
clean.  After  each  time  that  it  is  used  it  should  be  thoroughly  rinsed 
in  a  chlorine  solution,  and  put  away  in  carliolized  oil  or  vaseline.  A 
great  deal  of  vesical  catai'rh  is  undoubtedly  lighted  up  by  foul  cath- 
eters. This  is  especially  the  case  in  hospitals,  where  the  same  in- 
strument is  often  used  on  a  number  of  patients. 

In  cases  of  commencing  or  established  paralysis  the  effect  of  the 
induced  electric  current  may  be  tried.  One  pole  thoroughly  insu- 
lated up  to  the  point  to  be  used  should  be  placed  in  the  bladder, 
anil  the  other  over  the  pubic  symphysis  and  loins,  letting  the  cur- 
rent flow  in  various  directions,  through,  over,  and  into,  the  affected 
organ.  The  German  authors,  especially  Winckel,  by  whom  this 
method  is  highly  recommended  in  this  and  like  affections,  say  that 
the  sitting  should  last  but  about  five  minutes. 

Forcibly  distending  the  uretlu-a  and  washing  out  the  bladder 
with  a  solution  containing  salicylic  acid  has  been  tried  and  recom- 
mended. I  can  not  see  the  expediency  of  this  unless  vesical  catarrh 
exists ;  and  even  then  washing  must  be  done  gently  and  carefully, 
and  without  previous  dilatation  of  the  urethra. 

Attention  should  be  paid  to  the  general  health.  The  food  should 
be  good  and  nourishing,  and  the  alimentary  canal  kept  in  a  proper 
condition  to  receive  and  digest  it.  AVines  (especially  champagne), 
beer,  and  ale  may  be  of  use.     I  can  at  least  say  if  stimulants  are 


FUNCTIONAL  DISEASES  OF  TIIK   BLADDEE.  f379 

ever  given  in  diseases  of  the  bladder  it  should  be  in  cases  like  these 
now  under  consideration.  These  ])atients  are  usually  more  com- 
fortable in  the  standing  or  sitting,  than  in  the  prone  posture,  be- 
cause then  the  weight  of  the  abdominal  viscera  replaces  to  a  cer- 
tain extent  the  natural  tonicity  of  the  organ.  As  they  are  usually 
M'orse  in  winter  than  in  summer  it  is  advisable,  if  the  case  is 
chronic  and  the  patient  able  to  bear  transportation  and  rich  enough 
to  meet  tlie  expense,  to  send  her  to  a  moderately  warm  climate 
during  the  winter  months.  This  will  apply  in  most  of  the  diseases 
of  the  bladder. 

If  the  trouble  be  purely  atonic,  camphor  or  musk  may  be  used 
internally.  Tincture  of  cantharides,  in  from  five  to  twenty  drop 
doses,  three  times  a  day,  has  been  recommended  as  a  vesical  excit- 
ant. I  can  not  indorse  its  use  without  the  caution  that  besides  the 
tendency  to  irritate  the  kidneys  and  produce  congestion  and 
nephritis,  it  may  light  up  a  severe  cystitis.  In  these  cases  it  may 
])roduce  serious  trouble  without  causing  much  pain  to  give  warning 
of  the  danger,  as  the  paralysis  lessens  the  sensitiveness  of  the  blad- 
der, so  that  destruction  of  tissue  may  occur  without  producing  the 
usual  pain  and  suffering. 

Strychnia  has  been  extensively  used  in  this  complaint,  and  with 
good  results  in  some  cases.  Its  failure  to  do  good  in  many  in- 
stances is  undoubtedly  due  to  the  fact  that  it  was  not  given  in  suffi- 
ciently large  doses.  It  may  be  safely  pushed  as  high  as  tlie  one- 
twentieth  of  a  grain  three  times  a  day,  stopping  for  a  few  days  if 
any  of  its  characteristic  symptoms  appear.  It  has  also  been  used 
hypodermically  in  the  neighborliood  of  the  bladder. 

Ergot  has  been  found  useful  in  cases  where  tlie  paralysis  was 
due  to  ex]30sure  to  cold,  or  prolonged  retention  from  any  cause. 
The  fresh  powder  has  been  recommended,  and  may  be  given  in  doses 
of  from  eight  to  sixteen  grains,  four  or  five  times  daily.  It  is  more 
pleasant  and  probably  more  effective  to  give  its  equivalent  of  the 
fluid  extract.  Alliers  has  used  it  with  decided  success  in  cases  of 
vesical  paralysis  due  to  centric  troubles,  such  as  apoplexy.  He  has 
used  as  much  as  forty-five  grains  in  the  twenty-four  hours.  It  is 
highly  spoken  of  also  by  Roth,  Jacksch,  and  others. 

Rutenberg  ("  AYienner  Med.  Wochenschrif t,"  1875,  No.  37)  has 
recommended,  in  cases  where  there  is  destruction  of  muscular  tissue 
or  incurable  paralysis  from  any  cause,  to  make  an  opening  into  the 
bladder  just  above  the  pubic  symphysis,  keeping  the  fistula  open, 
and  closing  the  urethra  by  operative  procedures.  The  ui-ine  can 
thus  be  retained,  unless  the  patient  bends  forward  and  downwai'd 


680  DISEASES  OF   WOMEN. 

or  lies  upon  lier  abdomen.  A  urinal  would,  of  course,  be  necessary 
to  protect  the  ])atient. 

I  think  I  should  prefer  to  produce  a  vesico-vaginal  fistula,  and 
adapt  an  apparatus  to  receive  the  urine. 

{h)  Incontinence  of  Urine. — Enuresis  nocturna  is  usually  an  affec- 
tion of  childhoud,  but  has  been  known  to  persist  up  to  the  age  of 
thirty  years.  In  some  children  it  is  hereditary,  the  mother  having 
suffered  in  early  years,  and  all  the  children  born  to  her  being  affected 
in  the  same  way.  Of  aU  cases,  these  are  the  most  difficult  to  manage. 
They  often  persist  until  pubert}',  when  they  recover  of  themselves. 
The  subjects  of  this  affection  are  usually  of  the  weak,  nervous  type, 
although  apparently  healthy  children  have  been  known  to  suffer 
from  it,  but  usually  only  at  intervals. 

These  cases  of  incontinence  may  be  divided  into  two  distinct 
varieties:  First,  the  anaesthetic  variety.  An  excellent  example  of 
this  class  is  seen  in  infants  who,  up  to  a  certain  age,  wet  the  bed  and 
their  diapers.  In  the  infant  this  is  not  disease  ;  it  is  simply  a  good 
normal  example  of  this  condition ;  the  incontinence  in  severe  fevers 
illustrates  the  abnormal  phase  of  the  same  thing.  Second,  the  hyper- 
aesthetic  variety,  which  is  really  nothing  more  than  irritable  bladder. 
Each  variety  may  exist  alone,  or  both  be  combined  in  the  one  case. 

In  the  first  variety  the  retaining  power  is  defective,  the  resisting 
power  of  the  sphincter  being  insufficient  to  retain  the  urine  or  wake 
the  child.  When  it  is  put  to  bed,  it  sleeps  soundly  through  the 
night,  and  the  nerve  susceptibility  to  urine-pressure  on  the  neck  of 
the  bladder,  being  lowered  beyond  the  normal  degree,  fails  to  wake 
the  little  subject  and  impress  it  with  the  necessity  of  calHng  the 
sphincter  muscle  into  action  sufficiently  to  resist  the  expulsive  power 
of  the  bladder- walls.  In  short,  in  sound  sleep  the  ])alance  between 
the  resisting  power  of  the  sphincter  and  the  contractility  of  the  walls 
of  the  bladder  is  disturbed,  and  the  urine  flows  away  without  the 
child's  even  dreaming  of  its  unfortunate  behavior. 

In  other  forms  of  this  affection  the  brain  takes  cognizance  of  the 
desire  to  urinate,  but  too  late  to  control  the  act.  This  is  seen  in 
children  who  awake  crying  when  imnation  is  but  just  begun  or  half 
finished.     In  this  case  the  fault  probably  lies  in  the  vesical  nerves. 

In  the  second  variety  there  is  an  irritable  condition  of  the  blad- 
der (vesical  hyperaesthesia),  which  renders  the  expelling  power 
greater  than  that  of  resistance  or  retention,  and,  while  the  will  and 
cerebration  generally  are  lost  in  sleep,  the  contents  of  the  bladder 
are  unconsciously  passed  before  the  subject  wakes  to  resist  the  act. 
Closely  allied  to  this  is  the  peculiar  affection  known  as  vesical  chorea, 


FUNCTIONAL  DISEASES  OF  THE  BLADDER.  681 

in  wliich  tlie  child  while  awake,  it  may  be  in  school,  in  church,  or 
at  play,  suddenly  experiences  the  sensation  that  it  is  about  to  make 
water,  but,  before  it  is  possible  to  resist,  the  urine  is  forcibly  sj^arted 
out.  There  are  usually  choreic  movements  of  other  muscles  or  groups 
of  muscles.  This  affection  is  the  most  annoyini^  when  the  little  ones 
are  nervous,  cross,  and  fidgety.  It  may  be  accompanied  by  nocturnal 
enuresis.  It  is  apparently  more  common  in  the  male  than  in  the 
female  child. 

An  irritable  condition  of  the  bladder  may  coexist  witli  an  an- 
£esthetic  condition  of  the  sphincter  vesicae — i.  e.,  the  two  causes  of 
incontinence  may  be  combined. 

Irritable  bladder,  it  should  be  remembered,  may  be  due  to  some 
systemic  condition — that  is,  a  simple  neurosis  or  to  abnormal  urine, 
or  reflex  irritation  from  anal  Assure,  ascarides  in  the  rectum,  fistula 
in  auo,  hfemorrhoids,  or  vulvitis. 

Enuresis  nocturna  is  not  only  a  filthy  habit,  and  a  source  of  great 
annoyance  to  parents,  but,  moreover,  by  keeping  the  genitals  wet 
and  irritable,  strongly  predisposes  to  masturbation.  Then,  too,  other 
serious  results  may  happen.  The  constant  wettings  are  dangerous, 
in  that  they  may  produce  many  serious  complaints  from  causing  the 
child  to  "  take  cold." 

Prognosis. — In  some  cases  the  cure  is  easily  and  speedily  ef- 
fected ;  in  others,  the  disease  cures  itself  at  or  just  after  puberty ; 
but  in  a  few — a  very  small  percentage — no  medical  or  other  means 
seem  to  aid  the  sufl^erer  at  all. 

Treatment. — That  the  treatment  is  not  uniformly  satisfactory  is 
seen  by  the  number  of  remedies  that  have  been  tried.  The  proper 
way — and  I  can  not  call  attention  to  this  too  often — here,  as  else- 
where, is  to  find  the  cause  producing  the  disease,  if  it  be  discovera- 
ble, and  it  generally  is.  The  treatment  will,  of  course,  differ  in  the 
two  classes,  and  be  greatly  modified  by  diathesis  and  idiosyncrasy. 
In  anaesthesia,  local  or  general,  stimulation  is  indicated.  In  hyper- 
SBsthesia,  irritability  should  be  allayed. 

Winckel,  Barclay,  and  Brugleman  speak  very  highly  of  the  use 
of  the  syrupus  ferri  iodidi,  the  last-named  gentleman  having  by  its 
use  cured  a  gii-1  perfectly  of  incontinence  in  the  sliort  space  of  four- 
teen days.  This  result  was  probably  due  more  to  the  effect  of  the 
medicine  on  the  blood  and  general  system  tlian  to  any  s]3ecific  action 
on  the  bladder.  The  sirup  of  the  iodide  may  be  given  in  from  ten 
to  thirty  minim  doses  three  or  four  times  daily,  according  to  the  age 
of  the  patient. 

Although  belladonna  has  been  lauded  by  many  as  a  specific  in 


682  DISEASES   OF  WOMEN. 

this  disorder,  its  success  is  by  no  means  general.  The  drug  is  usually 
given  by  the  mouth  in  from  five  to  twenty  drop  doses  of  the  officinal 
tincture.  It  would  be  better  to  begin  with  small  doses  in  young 
children,  and  gradually  increase  tbem ;  for,  although  n(j  serious  re- 
sults may  come  from  its  exhibition  in  the  routine  dose — ten  drops — 
the  parents  may  be  greatly  alarmed  by  the  peculiar  redness  of  the 
skin  produced  in  some  cases.  It  is  maintained  by  some  medical  men 
that  the  good  effects  are  not  obtained  unless  the  administi'ation  be 
pushed  to  tlic  appearance  of  the  scarlet  rash.  There  is,  I  think,  no 
proof  of  the  correctness  of  this  statement. 

A  combination  of  belladonna  and  chloral  hydrate  has  been  used 
and  well  spoken  of.  Winckel,  however,  though  using  them  in  cer- 
tain cases  tor  a  long  time,  and  daily  increasing  the  amount  of  chloral, 
has  had  but  poor  results,  and  even  in  those  cases  where  the  patients 
improved  the  benefit  was  seldom  permanent.  These  drugs  may  be 
given  singly  or  together,  in  suppository  or  by  the  mouth.  If  given 
together,  they  should  not  be  combined  uutil  the  time  when  they  are 
administered,  lest  the  chloral  lose  its  power. 

Narcotics  with  tinctura  ferri  chloridi  have  been  recommended 
by  Campbell  Black.  Winckel  speaks  well  of  five  to  ten  drop  doses 
of  tinctura  thebaica,  to  a  child  fro-i  ten  to  fourteen  years  of  age,  just 
before  retiring.  According  to  Sauvage,  cold  baths  and  cold  douches 
to  the  spine  at  night  are  of  great  service. 

Dr.  Kelp  ("  Le  Mouvement  Med.")  reports  that  he  has,  on  sev- 
eral occasions,  drawn  attention  to  the  value  of  subcutaneous  injec- 
tions of  the  nitrate  of  strychnia  in  the  treatment  of  obstinate  cases 
of  nocturnal  incontinence.  He  practices  the  injections  in  the  neigh- 
borhood of  the  sacrum.  A  single  injection  of  a  very  small  (piantity 
of  the  drug  suflices  to  arrest  the  affection  for  a  certain  time,  and 
when  it  reappears  the  operation  can  be  repeated.  His  latest  paper 
cites  the  case  of  a  young  woman,  eighteen  years  of  age,  who  had 
suffered  from  enuresis  every  night  for  several  months ;  it  came  on 
after  an  attack  of  scarlatina,  and  persisted  in  spite  of  all  precautions. 
The  first  injection  produced  a  respite  of  several  nights,  and  the 
second  produced  a  permanent  cure.  The  patient  was  a  strong, 
healthy  girl,  and  had  never  suffered  from  enuresis  previous  to  the 
attack  of  scarlatina. 

Such  a  plan  of  treatment  I  regard  as  useful  only  when  there  is 
deranged  innervation,  characterized  by  weakness.  It  would  be  diffi- 
cult to  get  a  child  to  submit  to  these  injections,  and  I  should  in  any 
case,  whether  child  or  adult,  expect  the  incontinence  to  return  as 
soon  as  the  strychnia  was  discontinued. 


FUNCTIONAL  DISEASES  OF  THE  BLADDER.  083 

In  cases  where  the  vesical  irritability  is  due  to  abnormality  of 
tlie  urine,  such  as  lithiasis,  oxaluria,  and  acidity,  these  conditions 
should  be  corrected  in  the  manner  I  have  already  pointc-d  out.  If 
to  ascarides,  anal  fissure,  and  that  class  of  rectal  trouble,  M^hen  the 
cause  is  i-enioved  the  result  will  usually  disappear  also.  In  imta- 
bility  the  usual  soothing  and  denuilcent  drinks,  such  as  have  been 
already  recommended,  should  be  used.  Oil  of  sandal- wood  has  acted 
remarkably  well  in  some  of  these  cases.  Bromide  of  sodium  and 
tincture  of  mix  vomica  have  been  effectual  in  some  cases. 

In  the  ancesthetic  variety,  where  the  anaesthesia  is  more  or  less 
marked,  special  or  local  and  general  stimulants  should  he  employed. 
Narcotics  are  as  hurtful  here  as  they  are  useful  in  the  hypersesthetic 
class.  Strychnia  by  the  mouth,  in  suppository,  or  hypodermically, 
often  produces  good  results,  as  also  quinine,  whether  the  presence 
of  malaria  is  suspected  or  not.  Tonic  and  astringent  injections  into 
the  bladder  are  sometimes  of  service.  In  cases  of  abnormally  small 
bladder,  forcibly  washing  it  out,  distending  the  organ  a  little  more 
each  time,  is  well  spoken  of.  In  one  such  case,  where  there  was 
irritability,  Winckel  produced  a  cure  by  first  injecting  a  solution  of 
nitrate  of  silver,  and  following  it  witli  sulphate  of  morphia.  This 
treatment,  however,  applies  more  to  the  irritable  than  to  the  anaes- 
thetic type.  The  little  patients  are  very  hard  to  operate  upon,  and, 
unless  great  care  is  exercised,  much  mischief  may  be  caused  by  local 
treatment. 

Winckel  claims  good  results  from  the  use  of  the  electric  current, 
applied  in  the  manner  I  have  spoken  of  under  the  head  of  paresis 
vesiccTe. 

When  the  bed- wetting  is  due  to  pure  carelessness,  laziness,  fear, 
or  dread  of  the  cold  air  in  rising,  in  idiots  and  half-witted  children, 
much  may  be  gained  by  proper  education. 

There  is  a  general  plan  of  prophylaxis  recommended  by  common 
sense,  viz.,  the  heartiest  meal  should  be  in  the  middle  of  the  day; 
but  little  water  should  be  taken  toward  evening ;  the  food  should  be 
plain  and  unseasoned ;  the  bowels  should  be  kept  regular ;  no  coffee 
or  tea  should  be  allowed ;  the  little  patients  should  be  put  to  bed 
early,  after  it  is  assured  that  the  bladder  is  first  thoroughly  emptied  ; 
they  should  he  upon  a  hard  bed,  with  not  too  much  covering;  the 
air  in  the  room  should  be  maintained  fresh  and  pure ;  the  genitals 
should  be  kept  clean  and  dry ;  no  i)laces  of  amusement  should  be 
visited  after  dark ;  and  they  should  be  awakened  occasionally  to 
urinate,  especially  at  about  the  time  the  parents  are  going  to  l)ed. 
When  it  is  discovered  that  they  have  wet  the  bed,  they  should  be 


084  DISEASES   OF   WO^rEN■. 

awakened,  and  talked  to  and  reasoned  with,  if  they  are  able  to  com- 
prehend what  is  said  and  meant.  Children  should  not  go  to  school 
too  early,  or  stay  too  long.  If  the  enuresis  be  due  to  masturbation, 
the  parents  must  be  cautioned  to  watch  closely,  and  to  use  everv 
means  in  their  power  to  stop  it.  A  child  should  never  be  whipj)(<l 
for  the  offense  or  misfortune  of  wetting  the  bed,  unless  the  inconti- 
nence be  due  to  pure  laziness. 

Owing  to  the  fact  that  incontinence  is  an  affection  of  childhood, 
and  occurs  but  seldom  in  women,  cases  will  not  be  given  to  illustrate 
what  is  said  in  the  text  on  that  subject.  This  omission  is  made  for 
the  additional  reason  that  partial  incontinence  due  to  displacements 
of  the  bladder  and  urethra  and  from  other  causes  will  be  discussed 
further  on, 

ILLrSTEATIVE    CASES. 

Paralysis  of  the  Bladder  followed  by  Incontinence  in  Case  of  In- 
sanity.— This  was  a  single  lady,  twenty-eight  years  of  age,  who  had 
been  insane  for  eight  months.  I  was  told  that  at  first  she  was  vio- 
lent, but  had  become  quiet  and  rather  demented  toward  the  time 
that  I  saw  her.  Her  physician  had  observed  for  some  time  that  her 
bowels  were  obstinately  constipated,  and  the  nurse  noticed  that  she 
had  great  difficulty  in  evacuating  the  bladder.  She  also  ajjpeared 
to  have  some  discomfort  in  that  region ;  finally,  she  went  for  over 
twenty-four  hours  without  urinating,  and  then  I  was  called  to  see 
her.  I  found  the  bladder  greatly  distended,  and  yet  I  could  not  see 
that  she  had  pain  or  tenderness  on  that  account.  The  catheter  was 
used,  and  three  and  a  half  pints  of  urine  were  removed.  After  this 
the  catheter  had  to  be  used  twice  in  twenty-four  houi*s  for  five  weeks. 
During  this  time  the  usual  means  were  tried  to  restore  the  function 
of  the  bladder,  but  without  effect.  The  urine  then  began  to  flow 
constantly.  AVhen  I  heard  of  this,  I  presumed  that  the  bladder  had 
become  overdistended,  and  that  the  nurse  who  used  the  catheter  had 
not  emptied  the  bladder.  This  I  found  was  not  the  case ;  the  blad- 
der was  empty.  The  incontinence  continued  until  the  patient  died 
of  general  paralysis. 

Paralysis  of  the  Bladder  from  Cerebro-spinal  Meningitis. — A  girl 
twelve  years  old  was  taken  with  cerebro-spinal  ineningiiis,  and  pre- 
sented the  usual  clinical  history  of  that  affection  until  the  seventh 
day  of  the  disease,  at  which  time  the  pain  had  subsided  to  a  great 
extent,  but  her  mind,  which  up  to  this  time  had  been  clear,  began 
to  wander.  Retention  of  the  urine  was  noticed  by  her  nurse,  who 
called  my  attention  to  the  fact.     I  fotmd  the  bladder  distended,  but 


FUXOTIONAL*  DISEASES   OF   THE    BLADDER.  685 

not  greatly  so.  She  was  asked  if  she  did  not  desire  to  urinate,  but 
she  answered  in  the  negative,  so  far  as  I  could  understand  her.  The 
catheter  was  used,  and,  although  the  distention  was  not  great,  the 
bladder  did  not  contract  well,  so  that  abdominal  pressure  was  neces- 
sary to  make  the  urine  flow  through  the  catheter.  The  use  of  the 
catheter  was  necessary  for  some  time,  during  which  she  improved  in 
her  general  condition,  the  mind  becoming  quite  clear.  She  then 
began  to  express  at  times  a  desire  to  urinate,  but  could  not  relieve 
herself.  Four  days  later  she  succeeded  in  urinating,  but  did  not 
completely  empty  the  bladder.  She  gradually  improved,  but  the 
catheter  was  passed  once  every  twenty-four  hours  for  a  week  longer. 
The  desire  to  empty  the  bladder  became  more  and  more  urgent,  and 
she  had  pain  in  the  urethra  in  urinating.  An  examination  of  the 
urine  at  this  time  showed  that  she  had  cystitis,  due,  I  believe,  to  the 
use  of  the  catheter.  The  cystitis  was  treated  according  to  my  usual 
methods,  and  she  made  a  good  recovery. 

Paralysis  of  the  Bladder  from  Progressive  Locomotor  Ataxia. — A 
lady  who  had  been  affected  with  locomotor  ataxia  for  more  than  a 
year,  came  under  my  care  for  retention  of  urine.  I  found  that  there 
was  some  decomposition  of  the  urine,  but  nothing  else  to  distinguish 
the  case  from  paralysis  of  the  bladder,  occurring  in  other  cases  of 
disease  and  injury  of  the  spinal  cord.  The  attendant  was  advised 
to  use  the  catheter  regularly,  and  to  wash  out  the  bladder  with  a 
solution  of  borax — one  drachm  of  borax  to  a  quart  of  warm  water. 
I  learned  subsequently  that  this  patient  had  incontinence  of  urine 
before  she  died, 

II.  Derangements  due  to  Abnormal  Conditions  of  the  Urine. — The 
bladder  being  made  to  contain  urine,  almost  constantly  uniform  in 
its  composition,  it  at  once  feels  and  responds  to  any  abnormality. 
If  the  aberration  is  only  occasional,  the  effects  are  slight  and  of  short 
dm-ation  ;  but,  if  the  abnormality  be  constant,  or  almost  so,  or  if  the 
altered  urine  has  a  hypersesthetic  surface  to  deal  with,  the  results  are 
more  annoying. 

Urine  which  is  too  acid  or  too  alkaline,  too  limpid  or  too  greatly 
concentrated,  acts  somewhat  like  a  foreign  body^ — it  irritates,  and 
the  bladder  inclines  to  expel  it. 

Deposits  of  any  of  the  urinary  solids  in  the  viscus  may  produce 
an  irritable  condition,  and,  if  unchecked,  lead  to  organic  disease  of 
the  bladder.  Uric  acid,  in  large  or  small  crystals,  in  little  masses, 
forming  gravel  and  minute  calculi,  the  amorphous  urates,  the  triple 
and  amorphous  phosphates  (these,  as  a  rule,  however,  occurring  only 
in  decomposition  of  the  urine),  and  oxalate  of  lime  may  give  rise  to 


686  DISEASES   OF    WOMf:X. 

considerable  trouble.  There  are  some  other  deposits,  such  as  cystine, 
that  are  of  such  rare  occurrence  that  they  need  not  be  mentioned  in 
this  list.  In  any  of  these  cases^  but  especially  when  there  is  a  de- 
posit of  uric  acid,  there  may  be  one  of  two  things  resulting;  an). 
in  order  to  treat  the  ease  properly,  they  must  be  borne  in  mind: 
Fii*st,  a  real  excess  of  the  salt  in  the  urine ;  and  second,  a  condition 
of  the  secretion,  where,  whether  the  amount  of  salt  present  be  nor- 
mal, or  less  or  more  than  normal,  it  will  be  precipitated  in  the  blad- 
der. 

As  an  example  of  the  first  may  be  mentioned  some  cases  of  d^.s- 
pepsia,  when,  owing  to  a  defect  in  either  primary  or  secondary  as- 
similation, the  salt  or  salts  are  eliminated  by  the  kidneys  greatly  in 
excess  of  the  normal.  Here  a  normal  or  even  an  abnormal  amount 
of  water  in  the  secretion  could  not  hold  them  in  solution,  and  they 
are  consequently  precipitated. 

As  an  exanijjle  of  the  second  may  be  taken  some  cases  of  hepatic 
disease,  in  which,  although  the  uric  acid  is  eliminated  in  abnormally 
small  amount,  it  is  precipitated  on  account  of  the  deficiency  of  water, 
excessive  acidity,  and  possibly  too  rapid  absorption  of  the  watery 
element  of  the  urine  while  in  the  bladder. 

In  some  cases  with  an  excess  of  salts,  there  may  be  excessive 
acidity  and  lack  of  water.  Some  forms  of  dyspepsia  are  notable 
examples  of  this,  and  as  low  nerve  condition  frequently  accompanies 
these  disorders,  the  abnormal  urine  meets  in  the  bladder  with  an 
irritable  mucous  membrane.  In  these  cases  the  acidity  is  quite  as 
hurtful  as  the  deposit. 

Deposits  of  oxalate  of  lime  in  the  bladder  are  not  so  common 
(except  in  lime-water  regions)  as  those  of  uric  acid.  In  cases  of  the 
persistent  deposit  of  oxalate  of  lime  in  the  urine,  known  as  oxaluiia, 
there  is  usually  marked  irritability  of  the  bladder.  This  has  been 
ascribed  by  some  to  the  presence  of  minute  octahedra  of  this  salt 
irritating  the  mucous  membrane.  It  is  more  than  likely,  however, 
that  the  derangement  of  the  general  nervous  system,  always  existing 
in  these  cases,  stands  as  a  pwjytei'  rather  thau  a  2^ost  hoc,  and  that 
the  bladder  difficulty  is  but  a  local  manifestation  of  the  general  dis- 
ease, and  consequently  a  pure  neurosis.  That  tlie  urine  of  oxaluiia 
does  possess  irritant  properties  there  is  but  little  doubt,  but  it  is 
hardly  likely  that  the  symptoms  here  occurring  would  be  produced 
unless  there  was  already  an  abnormal  condition  of  the  vesical  mucous 
membrane. 

Many  authors  hold  that  the  high  specific  gravity  of  a  single  speci- 
men of  urine  must  not  be  taken  as  an  evidence  of  concentration,  or 


_  FUNCTIONAL  DISEASES  OF  THE   BLADDER.  687 

i 

the  low  gravity  of  excessive  limpidity  of  the  twenty- four  hours' 
urine.  This  is  very  true  in  regard  to  the  total  amount  passed  in  a 
day ;  but  as  the  bladder  has  to  do  each  time  only  with  the  urine  in 
it  at  that  time,  it  will  be  well  in  these  cases  to  examine  several  spec- 
imens in  a  day,  rather  than  to  depend  for  information  on  the  reac- 
tion of  the  total  amount  of  urine  passed. 

Urine  may  irritate  the  same  patient  at  one  time  from  being  too 
Hmpid,  and  at  another  time  from  being  too  highly  concentrated. 
These  variations  must  be  carefully  watched  and  treated.  A  bladder 
that  is  irritable  at  all  times  and  witli  urine  of  varying  reactions, 
may  be  set  down  as  one  affected  with  a  pure  neurosis,  if  no  organic 
cause  be  found,  for  the  urine  could  not  work  the  mischief  continu- 
ally, if  normal  at  certain  periods. 

Symptomatology. — Patients  suffering  from  this  affection  usually 
complain  of  frequent  urination  and  vesical  tenesmus. 

In  some  cases  there  is  smarting  pain  in  the  urethi'a  during  the 
passing  of  water  and  for  some  time  after,  and  tliere  is  a  sense  of  heat 
in  the  bladder  and  a  desire  to  urinate  which  are  not  fully  relieved 
when  the  bladder  is  empty.  This  last-named  symptom  belongs 
more  especially  to  those  cases  in  which  the  mine  salts  are  in  excess. 
When  the  urine  is  defective  in  the  salts,  that  is,  when  the  urine  is 
limpid,  the  only  symptom  present  is  frequent  urination.  It  will  be 
observed  that  these  symptoms  are  the  same  as  those  presented  in  a 
variety  of  affections,  and  hence  can  not  be  depended  upon  in  making 
a  diagnosis. 

Diagnosis. — The  diagnosis  must  be  made  by  escludino-  all  other 
conditions  which  give  rise  to  this  derangement  of  function,  and  by  re- 
peated examinations  of  the  urine,  which  will  show  its  abnormal  state. 

Prognosis. — The  rehef  of  this  class  of  cases  w^ll  depend  upon 
the  possibility  of  correcting  the  constitutional  affections  which  pro- 
duce the  pathological  state  of  the  urine. 

In  case  the  abnormalities  of  the  urine  persist  for  a  long  time 
cystitis  and  m-ethritis  may  be  produced.  I  am  sure  that  I  have  seen 
cystitis  which  could  be  traced  to  long  continued  abnormal  states  of 
the  urine. 

Causation. — In  discussing  the  pathology  of  this  class  of  func- 
tional derangements  the  causes  which  produce  them  have  been  fully 
brought  out,  so  that  they  need  not  be  repeated  here. 

Treatment. — In  cases  of  concentration  of  the  urine  due  to  acute 
febrile  action,  the  patient  should  be  liberally  supplied  with  cooling 
drinks ;  and  as  in  these  affections  the  urine  is  generally  too  acid,  the 
slightly  alkaline,  effervescing  waters  will  be  found  useful. 


G88  DISEASES  OF   WOMEN. 

In  digestive  troubles,  with  excessive  aciility  or  saline  deposit,  at- 
tention sliould  be  paid  to  diet,  bathing,  and  regularity  of  the  bow- 
els, as  well  as  the  taking  of  a  proper  amount  of  exercise.  Where 
deposits  of  uric  acid  take  place  there  is  usually  some  defect  in  either 
primary  or  secondary  assimilation.  This  should  be  sought  out  and 
remedied.  In  excessive  acidity  with  deposits  of  uric  acid,  the  alka- 
line carbonates  act  in  a  double  way  ;  lirst  by  neutralizing  the  acid- 
ity of  the  urine,  and  second  by  acting  on  the  liver  to  lessen  the 
amount  of  uric  acid  produced.  The  follovring  is  a  very  pleasant 
and  efficient  proscription  in  these  casefe. 
]^.     Potassii  bicarbonatis, 

Potassii  citratis iia  3  ss. 

Syrupi  simplicis 3  iv. 

M.  

Sig.  Take  3i  i^i  half  a  tumbler  of  water,  adding   3  ij  of  lemon- 
juice.     Drink  while  effervescing. 

The  late  Prof.  Ai'mor  gave  some  very  excellent  ad  Wee  regarding 
the  management  of  such  cases,  which  I  will  reproduce  in  his  own 
words : 
/  "  When  the  urine  is  acid  in  any  of  the  forms  of  cystic  irritation, 

great  relief  is  experienced  from  the  use  of  alkalies,  especially  when 
administered  in  an  infusion  of  buchu.  I  regard  buchu  as  a  remedy 
of  undoubted  efficacy  in  all  cases  of  vesical  irritability.  It  seems 
to  possess  similar  properties  over  the  urinary  tract  that  bismuth  does 
over  the  intestinal,  and  is  an  admirable  vehicle  in  which  to  adminis- 
ter the  various  alkalies.  The  citrate  of  potash  with  buchu  is  an  excel- 
lent combination  where  we  desire  the  joint  action  of  these  remedies. 
The  liquor  of  potash,  the  bicarbonate  and  the  iodide  of  potash  also 
possess  a  high  degree  of  utility  in  the  class  of  cases  refej-red  to,  and 
their  therapeutic  action  is  certainly  never  disturbed  by  administer- 
ing them  in  an  infusion  of  buchu. 

"  In  irrital)le  conditions  of  the  bladder  associated  with  a  gouty 
and  lithic-acid  diathesis,  the  carbonate  of  lithium  is  a  remedy  of  un- 
doubted efficacy.  It  perhaps  excels  the  preparations  of  potiish  in 
rendering  uric  acid  and  the  urates  soluble.  Dr.  Murchison  speaks  in 
liiffh  terms  of  the  followino-  conibination  : 

"  Carbonate  of  lithium 3  ss. 

'•  Benzoic  acid 3  xiij. 

"  Dissolve  the  acid  in  ten  per  cent  biborate  of  soda  ;  then  add 
lithia  and  distilled  water  to  make  3  vj. 

"  A  teaspoonful  four  times  a  day,  with  copious  draughts  of 
water." 


FUNCTIONAL  DISEASES   OF  THE  BLADDER.  689 

Limpid  urine  is  usually  due  to  some  general  nervous  trouble  or 
cerebral  disease.  In  such  cases  treatment  should  be  directed  to  the 
original  disease. 

Deposits  of  amorphous  or  triple  phosphates  are  rare,  unless  tliere 
is  some  organic  disease  of  the  bladder.  Where  the  deposits  are  not 
due  to  decomposition,  some  decided  nerve  trouble  is  usually  \)re&- 
ent,  and  here,  as  in  limpidity,  the  attention  must  be  turned  to  treat- 
ment of  the  general  trouble. 

In  oxaluria  attention  nmst  be  paid  to  the  moral,  mental,  and 
physical  condition,  and  time  must  not  be  wasted  in  treating  mere 
symptoms.  In  the  way  of  medication,  the  following  prescription, 
is  looked  upon  by  many  as  almost  specific  in  these  cases  : 

]^.     Acidi  nitro-muriatici  diluti 3  "^-vj- 

Tinctures  nucis  vomicae 3  iij- 

Olei  gaultherise TTj.xij. 

Aquse  ad 3  iv. 

M.  

Sig. —  3  i  in  water  before  each  meal.  In  some  cases  the  pure 
non-diluted  acid,  freshly  made  up,  acts  better  than  the  dilute.  It 
should  be  given  in  smaller  doses  than  the  dilute,  and  in  j)lenty  of 
water  at  the  time  of  taking  it.  In  all  cases  of  urinary  deposits, 
water  should  be  freely  taken,  and  the  greatest  attention  paid  to 
general  hygiene  and  to  mental  and  moral  surroundings. 

Many  of  the  slightly  alkaline  mineral-spring  waters  will  be  found 
of  use,  acting  gently  on  the  liver,  flushing  the  kiSneys  and  urinary 
organs,  and  slightly  relaxing  the  bowels.  A  considerable  quantity 
should  be  taken  in  the  course  of  the  day  when  the  stomach  is  empty. 

ILLTJSTKATIVE    CASES. 

Irritation  of  the  Bladder  from  Abnormal  Urine. — A  patient  forty 
three  years  old,  large  and  stout,  had  menstruated  scantily  for  sev- 
eral months  and,  as  the  flow  diminished  in  quantity  and  duration, 
she  gained  in  flesh  but  not  in  strength.  She  had  a  very  good  appe- 
tite and  lived  very  well,  but  she  did  not  feel  in  her  usual  health. 
She  noticed  a  gradual  disinclination  to  mental  and  physical  activity. 
Backache,  headache,  and  wandering  pains  here  and  there,  occasionally 
annoyed  her.  After  these  symptoms  had  continued  for  a  time  urin- 
ation became  more  frequent  and  at  times  slightly  painful.  She 
noticed  also  that  there  was  a  sediment  in  the  urine.  These  sj-mp- 
toms  caused  her  to  seek  advice  from  the  fear  that  she  had  Bright's 
disease.  She  was  found  to  possess  a  very  good  organization ;  and 
there  was  no  organic  disease  of  any  kind  present.  All  the  evi- 
45 


690  DISEASES  OF  WOMEN. 

dences  of  excreraentitious  plethora  were  well  expressed  in  the  abun- 
dant adipose  tissue,  coated  tongue,  constipation,  muddy  appear- 
ance of  the  eyes,  full  slow  pulse,  shortness  of  breath  on  exertion, 
depression  of  spirits,  disposition  to  sleep,  and  at  times  sleepless- 
ness. The  urine  was  examined,  and  found  to  be  slightly  alkaline. 
The  specific  gravity  was  1030.  There  was  neither  albumen  nor 
casts.  The  salts  of  the  urine  were  in  excess,  but  as  a  quantitative 
analysis  was  not  made  the  exact  composition  of  the  urine  was  not 
ol)tained.  The  diagnosis  of  general  excrementitious  plethora  from 
imperfect  elimination  was  made,  and  the  frequent  urination  was  at- 
triljuted  to  the  abnormal  condition  of  the  urine.  Ten  grains  of  j'il. 
hydrarg.  and  one  grain  of  ipecac  were  given  at  bed-time  and  a  Seid- 
litz  powder  an  hour  before  breakfast  the  next  morning.  This  was 
repeated  in  five  days. 

The  quantity  of  food  was  diminished — she  had  been  taking  ex- 
tra diet  to  make  her  stronger — milk  was  the  chief  article  permitted, 
witli  a  very  little  animal  food  once  a  day.  A  Turkish  bath  twice  a 
week  and  gradually  increased  out-of-door  exercise.  The  bowels 
were  kept  rather  free  by  giving  a  dose  of  Congress  water  an  hour 
before  breakfast  every  morning.  Under  this  treatment  she  im- 
proved in  every  way.  The  irritation  of  the  bladder  subsided,  and 
has  not  returned.     The  urine  is  now  nonnal. 

Frequent  Urination  from  Abnormal  TJrine. — An  unmarried  lady, 
thirty  years  old,  of  good  constitution,  very  ambitious  and  energetic, 
overtaxed  herself  during  the  winter,  and  toward  the  end  of  the 
season,  began  to  suffer  from  frequent  urination  and  a  sense  of  burn- 
ing heat  in  the  bladder  and  urethra  after  urinating.  After  a  time 
these  symptoms  became  very  annoying,  and  as  she  was  a  nervous, 
sensitive  person,  she  suffered  quite  severely.  She  was  found  to  be 
quite  out  of  health.  Her  appetite  was  poor  and  her  digestion  im- 
paired ;  she  was  constipated,  and  suffered  from  rheumatic  pains  in 
her  joints,  and  in  the  back  of  her  neck.  In  short,  she  gave  a  fairly 
good  history  of  dyspepsia  and  neura?sthenia  plus  the  irritation  of 
the  bladder  which  was  her  chief  source  of  discomfort.  The  urine 
was  diminished  in  quantity,  dark  in  color,  very  acid,  and  of  high 
specific  gravity  ;  no  albumen  or  casts  were  found.  She  had  been 
quite  free  from  any  affections  of  the  pelvic  organs,  the  present  dis- 
turbance of  the  bladder  being  the  only  suffering  she  had  ever  had  in 
that  regard. 

My  first  impression  was  that  she  had  cystitis,  but  there  were  no 
products  of  infiammation  found  in  the  lu'ine,  and  therefore  the  diag- 
nosis was  made  as  stated  above. 


FUNCTIONAL  DISEASES  OF  THE   BLADDER.  691 

Peptonized  milk  was  ordered  with  raw  eggs,  and,  in  addition, 
barley  gruel,  clear  soups,  and  bread.  Two  drops  of  liquor  amnioniaj 
in  a  wine-glass  of  water  were  given  every  two  hours  nntil  the  urine 
became  normal.  Her  bowels  were  kept  regular  by  small  doses  of 
Rochelle  salts  and  creaui-of-tartar  taken  in  the  morning. 

Rest  was  insisted  upon,  and  massage  every  third  day.  As  soon 
as  the  urine  became  less  acid  and  dense,  she  obtained  some  relief, 
but  was  not  restored  to  her  usual  condition.  It  was  not  until  her 
general  health  had  been  improved  that  the  urine  became  normal  and 
the  irritation  of  the  bladder  finally  left.  An  interesting  point  in  the 
treatment  was  observed.  For  a  time  she  was  partially  relieved  by 
the  alkaline  remedies,  but,  when  she  ceased  taking  them,  the  irrita- 
tion of  the  bladder  returned. 

When  her  general  health  was  restored  by  rest  and  tonics  the 
urine  became  normal,  and  the  irritation  of  the  bladder  disappeared 
entirely. 

At  the  present  time  I  have  a  lady  under  treatment  for  specific 
disease  of  the  uterus;  during  the  last  four  weeks  she  has  had  irrita- 
tion, causing  frequent  urination.  She  obtains  relief  by  drinking 
very  freely  of  lithia  water. 

Case  of  Baruria  (by  Dr.  Samuel  West). — The  patient,  aged  thirty- 
nine,  complained,  after  catching  cold,  of  pains  and  aching  in  her 
limbs,  w^bich  became  severe  enough  after  a  week  to  keep  her  in  bed. 
When  admitted,  these  pains  continued,  but  there  was  swelling  of 
joints.  The  temperature  was  100°,  and  she  perspii'ed  freely,  but  the 
sweat  did  not  smell  sour.  The  urine  had  a  specific  gravity  of  lOlO, 
and  yielded  copious  crystals  of  nitrate  of  urea,  with  nitric  acid.  Her 
appetite  had  been  for  some  days  almost  absent,  and  in  the  hospital 
she  took  but  a  little  milk  or  beef-tea.  For  two  days  the  condition  of 
the  urine  was  the  same,  and  the  percentage  of  urea  5'1.  This  per- 
centage gradually  fell  to  normal,  and,  as  it  did  so,  all  the  patient's 
symptoms  disappeared.  The  case  was  regarded  as  one  of  bararia. 
The  account  of  the  case  given  by  Prout  was  summarized  and  com- 
pared with  the  present  case,  and  reference  was  made  to  other  authors, 
by  some  of  whom  the  existence  of  the  affection  was  questioned, 
while  by  others  it  was  not  referred  to.  A  somewhat  similar  case, 
the  result  of  overfeeding  and  constipation,  has  been  described,  in 
which  like  symptoms  were  associated  with  a  high  percentage  of  urea, 
and  disappeared  when  the  amount  became  normal. 

III.  Derangements  of  Function  due  to  Affections  of  the  Pelvic 
Organs  other  than  the  Bladder. — Functii^iial  diseases  of  the  bladder, 
caused  by  disorders  of  the  neighboring  pelvic  organs,  are  frequently 


692  DISEASES  OF   ^YOMEN. 

met  with  in  practice.  In  this  class  the  vesical  trouble  is  secondary 
to  some  primary  and  more  important  affection,  but  the  derangement 
of  its  function  is  often  the  most  prominent  and  troublesome  symp- 
tom ;  hence  it  is  important  to  understand  its  relation  to  the  primary 
disease,  in  order  to  make  a  correct  diagnosis,  and  to  treat  such  cases 
properly. 

This  class  of  functional  disorders  frequently  resembles  in  history 
some  of  the  organic  diseases  of  the  bladder,  so  that  care  is  necessaiy 
to  distinguish  the  one  from  the  other.  AVhat  I  may  say  upon  the 
subject  will  have  reference  to  diagnosis  only.  When  we  know  that 
the  bladder  trouble  is  due  to  disease  of  some  other  organ,  attention 
is  at  once  turned  to  the  primary  affection.  These  facts  must  be 
borne  in  mind,  and  the  symjDtonis  not  mistaken  for  the  disease. 

Diseases  of  the  rectum  affect  the  bladder  sympathetically.  Irri- 
tation and  pain  in  the  rectum  from  any  cause  affect  the  bladder  more 
or  less.  Chronic  haemorrhoids  will  cause  frequent  urination,  and 
so  will  rectal  fissure,  especially  after  defecation.  Abscesses  in  the 
neighborhood  of  the  rectum  will  frequently  cause  retention  of  urine. 

One  very  interesting  case  of  this  kind  occurred  in  the  practice 
of  my  friend  Dr.  Gushing.  The  patient  had  an  abscess  in  the  neigh- 
borhood of  the  rectum  which  caused  retention  of  the  urine,  and  this 
in  turn  caused  acute  renal  disease.  After  the  bladder  had  been 
emptied  and  kept  from  overdistention  for  some  time,  the  urine  was 
examined  and  found  to  contain  albumen  and  casts.  She  made  a 
rapid  recovery,  and  all  evidence  of  kidney-disease  soon  disappeared. 

Yeiy  troublesome  vesical  irritation  may  come  from  asearides. 
Tlie  itching  of  the  anus  and  rectum,  caused  by  these  troublesome 
little  worms,  keeps  up  an  almost  constant  desire  to  urinate.  Chil- 
dren are  most  troubled  with  these  parasites,  but  women  often  suffer 
in  the  same  way. 

Marion  Sims  points  out  the  interesting  fact  that  almost  all  cases 
of  vaginismus  are  accompanied  by  an  irritable  condition  of  the  blad- 
der, and  that,  as  the  tenniual  fibers  of  the  hymen  often  extend  from 
the  meatus  to  the  vesical  neck,  cystospasm  may  in  these  cases  be  due 
to  reflex  nerve  irritation.  An  attempt  to  catheterize  these  patients 
is  as  liable  to  cause  spasm  of  the  bladder  as  an  analogous  attempt  to 
examine  the  uterus  would  be  to  produce  vaginismus.  In  these  cases 
the  hymen  should  be  excised,  and  the  vaginismus  treated  after  the 
usual  methods. 

Acute  pelvic  peritonitis  and  cellulitis  cause  great  distress  in  many 
cases  by  their  effect  on  the  bladder.  A  constant  desire  to  urinate, 
without  the  ability  to  make  suflicient  straining  effort  to  accomplish 


FUNCTIONAL  DISEASES   OF  THE  BLADDER.  693 

the  object,  is  very  often  observed  in  all  these  acute  pelvic  inflamma- 
tions. Thedisturbancc  of  the  bladder  is,  of  course,  only  a  symptom 
of  the  primary  and  more  important  trouble,  and  simply  requires  to 
be  mentioned  here.  The  after-effects  of  pelvic  peritonitis  are  what 
I  especially  desire  to  call  attention  to  at  present. 

The  adhesions  formed  by  the  products  of  the  inflammation  of 
the  pelvic  peritoniteum  are  in  some  cases  sutflcient  to  prevent  the 
normal  fllling  of  -the  bladder,  and  frequent  urination  then  becomes 
a  necessity.  This  derangement  of  function  generally  exists  alone. 
The  urine  is  retained  without  trouble  up  to  a  certain  amount ;  it  is 
passed  without  pain,  and  no  vesical  tenesmus  follows  evacuation. 
Unless  the  contraction  of  the  bladder  is  great,  and  the  frequent 
necessity  to  urinate  very  troublesome,  patients  rarely  consult  a  phy- 
sician for  it. 

Paralysis  of  the  bladder  with  retention  may  be  caused  by  a  pecul- 
iar condition  of  oedema,  by  which  the  detrusors  are  rendered  power- 
less to  act.  It  is  usually  caused  by  disease  of  the  cervix  uteri,  para- 
metritis, or  peritonitis. 


CHAPTER  XXXIX. 

METHODS    OF    EXPLORATION    OF    THE   BLADDER   AND    URETHRA. 

Preparatory  to  the  study  of  organic  diseases  of  the  bladder  and 
urethi'a,  I  desire  to  call  attention  to  the  methods  and  means  of  ex- 
ploring the  bladder  and  urethra,  and  to  some  of  the  phj^sical  signs 
of  disease  obtained  thereby. 

In  all  cystic  affections  the  urine  should  be  carefully  examined, 
both  chemically  and  microscopically.  It  is  not  necessary  for  me  to 
describe  the  methods  to  be  employed  in  this  examination;  they  will 
be  found  in  the  various  books  published  on  that  subject. 

If  an  examination  of  the  urine  does  not  make  the  diagnosis  clear, 
attention  should  be  directed  to  a  physical  exploration  of  the  bladder 
and  urethra.  For  this  purpose  either  a  digital  or  an  endoscopic  ex- 
amination may  be  made.  Digital  examination  per  vaginam  is  one 
of  the  most  valuable  means  of  investigating  the  bladder  and  urethra. 
By  this  and  by  the  bimanual  touch  the  physical  signs  of  many  of  the 
affections  of  these  organs  can  be  readily  obtained. 

The  method  of  making  these  examinations  is  exactly  the  same  as 
practiced  in  examining  the  uterus.  The  vaginal  touch  reveals  the 
position  of  the  bladder  and  urethra,  the  degree  of  their  sensitiveness, 
the  location  of  tenderness,  if  any  is  present,  the  increase  or  diminu- 
tion of  elasticity,  and  the  state  of  their  walls,  as  regards  thickening 
or  irregnlarity.  Distortions  of  the  urethra  fi'om  neoplasms  or  the 
products  of  inflammation  can  also  be  detected  in  this  way. 

The  bimanual  touch  will  show  whether  the  bladder  is  full,  empty, 
or  partially  distended,  and  any  foreign  body  of  considerable  size  can 
be  felt  in  the  bladder  in  case  the  abdominal  walls  are  not  too  rigid. 
As  a  means  of  detecting  stone  in  the  bladder  of  women,  the  biman- 
ual touch  is  the  easiest,  safest,  and  surest  of  all  methods  of  explora- 
tion. The  presence  of  neoplasms  can  be  discovered  in  this  way, 
although  their  composition  can  not  be  clearly  made  out.  In  some 
cases  it  is  necessary  to  give  an  anaesthetic  to  relax  the  parts  before 


METHODS   OF  EXPLORATION. 


695 


a  satisfactory  bimanual  examination  can  l)o  made.  There  arc  many 
advantages  gained  in  ansestlietizing  the  patient  wliile  making  a  bi- 
manual examination,  but  some  of  the  most  important  signs  may  be 
lost  by  the  unconsciousness  of  the  patient,  sucb,  for  instance,  as  tlie 
location  of  tenderness.  On  that  account  I  prefer  in  critical  cases  to 
make  an  examination  both  without  and  with  anaesthesia.  It  is  also 
well,  when  the  object  is  to  search  for  foreign  bodies,  like  stone  or 
tumors  of  any  kind,  to  have  a  few  ounces  of  urine  in  the  bladder, 
unless  that  much  gives  the  patient  pain.  The  longer  I  practice  -the 
more  I  depend  upon  this  method  of  examination. 

Another  method  of  examination  is  by  means  of  the  endoscope. 
For  this  purpose  I  devised  and  have  employed  for  years  an  endo- 
scope which  has  proved  of  great  service.  This  instrument  is  com- 
posed of  three  parts.  A  glass  tube  {a,  Fig.  226)  is  shaped  like  the 
ordinary  test  tube 
used  by  chemists, 
except  that  the 
mouth  is  a  little 
more  flaring.  The 
second  part  (&, 
Fig.  226)  is  com- 
posed of  two  pieces 
— a  mirror  and  its 
holder.  A  piece 
of  very  thin  silver 
plate  is  made  to  fit 
nearly  the  whole  length  of  the  inside  of  the  glass  tube,  and  about 
one  third  of  its  circumference.  To  one  end  of  this  arrangement  the 
mirror  is  attached  at  an  angle  of  about  100°.  At  the  other  end  a 
delicate  handle  projects  at  an  obtuse  angle.  This  part  of  the  instru- 
ment looks  like  a  section  of  a  tube  that  has  been  divided  into  three 
equal  parts  by  longitudinal  section,  with  a  mirror  attached  at  one  end 
and  a  handle  at  the  other.  This  piece  is  made  perfectly  black  on 
the  inside,  and  answers  two  purposes — it  holds  the  mirror,  and,  when 
placed  in  position  for  use,  darkens  one  side  of  the  glass  tube. 

It  will  be  seen  that  the  mirror  can  be  moved  forward  or  back- 
ward, and  turned  around  ;  so  that  when  the  tube  is  introduced  into 
the  urethra  or  bladder,  the  ex^^osed  internal  surfaces  can  be  brought 
into  view  by  moving  the  mirror  while  the  tube  remains  stationary. 

Fig.  225,  shows  the  glass  tube  placed  inside  of  a  fenestrated 
hard-rubber  speculum ;  and  Fig.  227  shows  the  glass  tube  inside  of 
a  speculum  that  is  open  and  beveled  at  the  end.     These  specula  ai'e 


Figs.  225-227. — Skene's  endoscope. 


69G  DISEASES  OF   WOMEN. 

used  in  making  ap])lieations  to  the  urctlira  and  bladder,  as  will  be 
described  hereafter. 

Tlie  method  of  using  this  instrument  is  as  follows  :  The  tube, 
with  the  mirror  inside,  is  introduced  into  the  urethra,  and  bladder 
also  if  an  examination  of  the  lower  portion  of  the  latter  be  desired. 
Light  is  then  thrown  into  the  tube  by  the  aid  of  a  concave  mirror. 
This  shows  that  portion  of  the  interior  of  the  urethra  or  bladder 
Avhich  is  opposite  the  mirror  and  in  contact  with  the  tube,  and  by 
moving  the  mirror  backward  and  forward  all  the  parts  to  be  exam- 
ined are  brought  into  view  in  regular  succession. 

Sunlight  may  be  used,  and  when  it  can  be  favorably  controlled 
it  answers  better  than  any  other  method  of  illumination.  It  very 
often  happens,  however,  that  the  light  is  insutfieient.  Dark,  cloudy 
days,  or  the  unfavorable  position  of  the  office-window,  often  make 
it  impossible  to  employ  sunlight  for  endoscopic  examinations.  On 
this  account  I  prefer  to  use  gaslight.  For  this  purpose  I  emj)loy  a 
gas-bracket,  which  is  movable  in  every  direction,  and  which  can  be 
iixed  in  any  position  desired.  By  this  means  the  light  is  easily  ad- 
justed to  the  position  of  the  patient  on  the  examination  table.  An 
argand  burner  with  the  ordinary  condensing  attachment  is  used, 
w^hich  gives  a  very  strong,  yet  soft,  steady  light.  There  is  one  ob- 
jection to  the  condenser,  and  that  is  the  difficulty  of  getting  the 
light  in  the  exact  place  where  it  is  needed.  On  this  account  I  pre- 
fer the  ordinary  argand  burner  with  the  glass  chimney,  such  as  ocu- 
lists employ  with  the  ophthalmoscope. 

The  color  of  the  mucous  membrane  lining  the  urethra  and  blad- 
der has  already  been  described  ;  but  it  nmst  be  borne  in  mind  that 
the  endoscope  modifies  the  color  to  some  extent.  This  is  especially 
so  when  examining  the  urethra.  If  a  large-sized  tube  is  used,  the 
parts  are  put  upon  the  stretch  and  the  pressure  of  the  glass  on  the 
mucous  membrane  interrupts  the  capillary  circulation  to  some  ex- 
tent, and  renders  the  color  as  seen  in  the  miri-or  a  jiale  pinkish 
white.  This  when  understood  does  not  interfere  with  the  examina- 
tion, as  it  only  tends  to  make  the  contrast  between  the  normal  and 
the  diseased  tissues  more  marked.  The  only  condition  where  the 
endoscope  might  lead  to  error  is  in  acute  genei'al  congestion  of  the 
urethra.  The  pressure  of  the  instrument  causes  the  congestion  to 
disappear  in  ]5art,  and  gives  the  idea  that  there  is  less  hyperremia 
tlian  there  really  is.  In  such  cases  I  use  the  speculum  or  the  ordi- 
nary endoscope  (Fig.  227),  and  thereby  remove  all  possibility  of 
error. 

By  a  little  practice  in  managing  the  light,  sufficient  dexterity  to 


METHOD   OF  EXPLORATION". 


09; 


examine  the  urethra  and  neck  of  tlie  bladder  thoroughly  and  satis- 
factorily can  soon  be  acquired. 

The  cystoscojDC  of  Nitze  and  Loiter  is  the  only  instrument  for 
thoroughly  investigating  the  bladder.  Bruck,  of  13reslau,  first  dis- 
covered the  principles  of  the  instrument,  and  Nitze  and  Leiter  per- 


Wall  of  the  bladder 


Water-pipes. 


fected  it.  Dr.  Willy  Meyer  gave  a  description  of  this  instrument 
in  ''  The  E"ew  York  Medical  Journal,"  April  21,  1888  : 

"The  cystoscope  (Fig.  227a)  consists  of  a  silver  tube  of  the 
shape  of  a  catheter,  in  the  short  beak  of  which  a  platinum  wire  is 
fastened.  The  latter  is  made  incandescent  by  means  of  an  electric 
current  which  passes  through  it,  and  then  darts  its  rays  upon  the 
wall  of  the  bladder  through  an  oval  window  in  the  concavity  of  the 
beak,  covered  with  transparent  quartz.  To  convey  the  current  of 
electricity  to  the  platinum,  an  insulated  wire  runs  through  the  whole 
length  of  the  shank ;  the  metal  of  the  tube  forms  the  connection 
with  the  opposite  pole.  No  cold  water  current  is  needed.  Accord- 
ing to  Nitze's  design,  a  telescope  is  introduced  into  the  shank  of  the 
cystoscope.  It  enlarges  and  magnifies  the  spot  coming  into  sight. 
Without  this  telescope  we  should  not  see  much  more  at  the  time 
than  a  spot  about  the  size  of  a  pea ;  with  it  we  are  enabled  to  in- 
spect a  portion  as  large  as  a  silver  dollar,  and  even  more. 

"  At  the  junction  of  beak  and  shank,  corresponding  to  the  con- 
cave side,  a  rectangular  prism  is  cemented  in,  the  hjqjotenuse-plane 
of  which  acts  as  a  mirror  on  account  of  the  total  reflection  of  the 
i^ays.  Thus  a  diminished,  inverted  real  picture  arises  in  the  shank 
of  that  wall  of  the  bladder  which  is  situated  at  a  riarht  anele  to  the 
longitudinal  axis  of  the  instrument;  and  opposite  the  prism.  It  is 
again  inverted  by  means  of  the  lenses  of  the  telescope,  and  thrown 
to  the  outer  end  of  it,  where  the  examining  person  looks  at  tlie  now 
upright  picture  through  the  magnifying  ocular  of  the  telescope. 


008 


DISEASES   OF   WOMEN. 


"  If  the  fundus  of  the  bladder  is  to  be  inspected  with  this  in- 
strument, it  must  be  turned  180°,  and  its  handle  deeply  depressed 
between  the  thighs  of  the  patient,  the  latter  l)eing  in  the  recum- 
bent (lithotomy)  position — the  best  for  examination  with  the  cjsto- 
scope. 

"This  manipulation  may  sometimes  be  very  painful.  To  avoid 
this,  a  second  instrument  (Fig.  227b)  is  made  with  the  window  for 


Telescope. 

Wall  of  the  bladder. 
Fig.  227b. 


t    il 
Water-pipes. 


the  incandescent  platinum  on  the  convex  side  of  the  beak.  There 
is  another  window  at  the  end  of  the  straight  tube  through  which 
the  observer  looks  with  the  telescope.  Of  course,  there  is  no  prism. 
"  Leiter's  cystoscope  shows  the  old  pattern  with  the  improvements 
mentioned.  A  key  near  the  handle  can  be  made  to  make  or  break 
the  current  by  turning  to  the  right  or  left  upon  or  from  an  ivory 
plate.  The  shank  of  the  instrument  is  somewhat  short  ;  its  telescope 
diminishes  the  part  in  view  a  trifle." 


Fig.  227c. 

Before  using  the  cystoscope,  the  beak  should  be  put  in  water, 
and  the  light  tested  to  see  that  it  is  in  working  order.  Glycerin 
should  be  used  to  lubricate  the  iustniment.  The  bladder  mnst  be 
washed,  provided  the  ui-ine  is  bloody  or  cloudy  with  mucus,  and 
then  be  partially  distended  with  from  five  to  six  ounces  of  clear 
water.  If  the  urine  is  quite  clear,  no  preliminary  washing  is  neces- 
sary. 


METHODS   OF  EXPLORATION".  699 

W.  Donald  Napier*  has  invented  a  probe  that  is  of  use  in  detect- 
ing foreign  bodies  in  the  bladder.  No  dilatation  of  the  urethra  is 
needed  for  its  nse.  It  consists  of  a  beaked  sound,  the  vesical  end 
of  which  is  covered  with  pure  metallic  lead.  This,  having  been  care- 
fully polished  with  soft  leather,  is  dipped  into  a  one-per-cent  solu- 
tion of  nitrate  of  silver,  which  gives  it  a  beautiful  black  coating. 
Before  use  it  should  be  carefully  examined  with  a  lens  to  see  that 
its  surface  is  perfect.  When  introduced  into  the  bladder,  if  any- 
hard  body  be  present,  such  as  a  calculus,  against  which  it  strikes,  au 
obvious  impression  is  made  upon  the  poHshed  surface. 

Exploration  of  the  bladder  by  dilatation  of  the  urethra  is  a  most 
valuable  means  of  diagnosis.  It  may  be  employed  in  various  de- 
grees. The  urethra  may  be  enlarged  only  sufficiently  to  admit  a 
fair-sized  endoscopic  tube,  or  it  may  be  dilated  sufficiently  to  admit 
the  finger.  I  will  first  give  the  methods  that  are  commonly  in  use, 
and  then  explain  the  plan  I  usually  adopt.  Although  there  are  rec- 
ords of  bloodless  dilatation  of  the  urethra  as  far  back  as  1502  (Beni- 
vienni),  1506  (Marcus  Sanctus),  and  1561  (Franco),  up  to  a  late  date 
the  operation  was  not  a  common  one.  Franco  used  an  instrument 
of  his  own  for  effecting  dilatation.  In  the  early  part  of  the  present 
century,  dilatation  by  means  of  the  compressed  sponge  and  Weisse's 
metal  dilator  was  somewhat  used,  but  more  for  the  extraction  of  cal- 
culi and  foreign  bodies  than  for  purposes  of  diagnosis. 

To  Simon,  however,  belongs  the  honor  of  improving  the  means 
employed,  and  introducing  the  subject  to  the  profession.  His 
method  is  this :  He  makes  a  single  incision  superiorly,  or  two  slight 
lateral  ones,  in  the  wall  of  the  meatus,  about  one  tenth  of  an  inch 
in  depth.  He  also  snips  the  urethro-vaginal  septum  to  the  depth  of 
about  one  fifth  of  an  inch.  This  is  done  to  relax  and  prevent  irregu- 
lar tearing  of  the  meatal  portion  of  the  urethra,  which  is  the  most 
rigid  and  undilatable  part  of  the  canal. 

He  next  introduces  a  hard-rubber  speculum,  shaped  somewhat 
like  a  cone,  the  cut  end  of  which  is  protected  by  a  rounded  piece  of 
wood  within.  His  largest  speculum  has  a  diameter  of  neai'ly  one 
inch ;  his  smallest  about  one  third  of  an  inch.  After  the  introduc- 
tion of  the  largest  one,  the  finger  can  be  readily  passed  into  the 
bladder,  and  the  whole  of  its  interior  explored,  save  the  antero-later- 
al  portion,  which  is  high  up,  and  difficult  to  reach.  The  narrowest 
urethra  may  in  this  manner  be  sufficiently  dilated  in  from  five  to  ten 
minutes. 

Simon  found  that,  without  any  bad  results  following,  an  adult 
woman  could  bear  the  introduction  of  a  speculum  having  a  circum- 


700 


DISEASES   OF   WOMEN'. 


ference  of  two  and  a  half  inches,  and,  when  the  necessity  for  marked 
dilatation  was  urgent  and  possibly  resulting  incontinence  of  com- 
paratively little  importance,  a  cone  having  a  circumference  as  high 
as  two  and  eight  tenths  inches  might  be  employed. 

In  girls,  specula  having  a  circumference  of  from  1-88  inch  td 
2-52  inches  may  be  used.  For  most  diagnostic  and  therapeutic  pm*- 
poses,  instruments  not  large  enough  to  produce  incontinence  are  usu- 
ally sufficient. 

"Winckel  has  used  Simon's  method  seven  times,  and  has  had  ex- 
cellent results ;  and  he  says  that,  although  the  incisions  made  at  the 
meatus  are  sometimes  opened  still  further,  and  that  a  fresh  one  may 
appear  under  the  clitoris,  it  is  of  little  moment,  as  the  presence  of 
the  dilator  stops  all  haemorrhage,  and  the  incisions  heal  readily.  In 
none  of  AYinckel's  cases,  although  he  watched  them  for  weeks,  was 
there  any  incontinence.  Heath,  in  digital  dilatation,  found  usually 
a  tearing  of  the  mucous  membrane  under  the  pubic  arch,  and  incon- 
tinence was  generally  present  for  at  least  twenty-four  hours. 

Instead  of  incising  the 
meatus,  I  generally  dilate  it 
slowly,  using  for  this  pur- 
pose the  bivalve  urethral 
speculum  (Fig.  228).  When 
used  as  a  dilator,  I  cover  the 
blades  with  a  piece  of  soft- 
rubber  tubing. 

Notwithstanding  the  testimony  to  the  contrary,  I  am  sure  that 
dilatation  of  the  uretlira  to  any  great  extent  is  dangerous.  There 
is  danger  of  lacerating  the  urethra  and  causing  incontinence,  which 
can  not  be  easily  cured.  Great  care  should  therefore  be  exercised 
in  dilatation,  and  it  should  not  be  resorted  to  at  all  unless  there  is 
some  marked  indication  for  it. 

In  cases  where  extreme  dilatation  of  the  urethra  does  not  prove 
sufficient  for  the  desired  end,  the  method  of  opening  into  the  blad- 
der through  the  vaginal  wall,  as  recommended  by  Simon,  may  be 
tried.  He  makes  an  incision  from  right  to  left  into  the  anterior 
vaginal  wall  just  in  front  of  the  os  uteri.  From  the  center  of  this 
incision  another  is  carried  forward  about  one  inch  in  length  in  the 
line  of  the  urethra,  thus  forming  a  T-incision.  Fine  tenacula  are 
then  fastened  into  the  bladder-wall  through  the  incision,  and,  with 
one  hand  pressing  the  abdomen,  and  by  traction  on  the  tenacula,  the 
bladder  is  pulled  down  through  the  incision  and  opened.  After  all 
necessary  procedures  are  completed,  the  edges  should  be  carefully 


Fig.  228. — Bivalve  urethral  speculum  (Skene). 


METHODS   OF  EXPLORATION.  701 

secured  by  sutures,  and  the  parts  will  heal  kindly.  The  bladder- walls 
coapt  readily  and  accurately. 

It  will  be  understood  that  this  important  operation  is  only  to  be 
performed  for  the  purpose  of  detecting  and  removing  foreign  bodies 
and  abnormal  growths  from  the  bladder,  and  possibly  to  close  vesico- 
intestinal tistuliB. 

Rapid  dilatation  of  the  urethra  is  chiefly  useful  for  the  purpose 
of  allowing  the  extraction  of  foreign  bodies  and  moderate-sized  cal- 
culi, for  cauterizing  the  mucous  membrane,  for  opening  htiemato- 
celes  (Spiegelberg),  for  allowing  the  introduction  of  endoscopic  tubes 
of  large  size  in  diagnosticating  cystitis,  calculi  (vesical  and  ureteral), 
ulceration,  vesico-intestinal  fistula,  polypi,  and  papilloma,  and  for  the 
local  treatment  of  these. 

Incision  into  the  bladder,  on  the  other  hand,  is  useful  in  cases 
where  calculi  or  other  bodies  are  too  large  for  safe  removal  by  the 
urethra,  the  removal  of  tumors  situated  high  up  anteriorly  or  antero- 
laterally,  in  operations  of  various  kinds  where  the  urethra  precludes 
free  movement  and  good  illumination,  as  in  sewing  up  large  vesico- 
intestinal fistulse.  I  may  observe,  in  passing,  that,  in  perforaiing 
operations  through  the  incision,  artificial  light  might  be  thrown  into 
the  bladder  by  means  of  a  small  curved  endoscopic  tube  and  concave 
mirror  in  the  urethra. 

In  cases  of  cystitis  and  vesical  ulceration,  this  operation  has  been 
performed  by  Sims,  Emmet,  Bozeman,  Simpson,  Hegar,  and  Simon, 
to  prevent  the  stagnation  and  decomposition  of  urine  in  the  diseased 
organ. 

Catheterization  of  the  ureters  has  been  performed  by  Simon  and 
Winckel,  but,  as  it  is  dillicult,  not  without  danger,  and  of  httle  prac- 
tical value,  I  shall  not  dwell  upon  it  here. 

In  connection  with  the  subject  of  physical  exploration,  I  give 
here  a  list  of  the  various  instruments  that  I  find  of  use  in  examin- 
ing and  operating  upon  the  bladder  and  uretlira.  They  are  as  fol- 
lows : 

Two  Skene's  Sims's  specula. 

One  Folsom's  speculum  (modification). 

One  Skene's  refiux  catheter  for  urethra. 

Two  silver  probes. 

One  sjDonge-holder  (steel). 

One  knife. 

One  Blake's  polypus-snare  (ear). 

One  Allen's  polypus-forceps  (ear). 

Two  glass  pipettes,  six  inches  long. 


702  DISEASES  OF  WOMEN. 

Two  licad-mirrors  on  same  strap,  three  and  one  half  inches  and 
one  and  one  half  inch. 

Skene's  bivalve  urethral  specula. 

Ordinary  urethral  endoscopes,  modified  by  Skene. 

Two  rectal  endoscopes  (long  and  short),  with  fenestrated  riibboi' 
specula. 

Three  urethral  endoscopes  (Nos.  13, 15, 17,  American),  with  be\- 
eled  rubber  specula. 

Two  beveled  urethral  endoscopes  (JSTos.  19,  21,  American),  with 
fenestrated  rubber  specula. 

One  brush  for  cleaning  endoscopes. 

Having  described  the  important  methods  to  be  employed  in  phys- 
ical exploration  of  the  bladder,  I  now  pass  to  a  consideration  of  the 
organic  diseases  of  the  bladder  and  urethra. 


CHAPTER  XL. 

OEGANIC   DISEASES    OF   THE   BLADDER. 

Having  treated  of  the  methods  of  physical  exploration  of  the 
bladder  and  urethra,  I  uow  invite  attention  to  the  organic  diseases 
of  these  organs,  and  shall  first  describe  those  which  affect  the  blad- 
der.    These  maj  conveniently  be  divided  into  three  classes : 

I.  Inflammatory ;  II.  Non-inflammatory ;  and  HI.  Neoplasms, 
hyperplasia,  and  atrophy. 

lo  Inflammation  of  the  hladder^  or  cystitis : 

Under  this  head  I  shall  include  all  forms  of  deranged  nutrition 
which  produce  disorders  of  function,  temporary  or  permanent  lesions 
of  structure,  and  the  morbid  material  knovm  as  the  "  products  of  in- 
flammation." 

Well-defined  typical  inflammation  presents  during  its  course  cer- 
tain peculiarities  which  are  characteristic  of  the  affection,  and  with- 
out the  existence  of  which  the  disorder  can  not  be  called  true  in- 
flammation. Inflammation,  however,  varies  in  character  with  the 
tissue  or  organ  involved  and  the  extent  or  intensity  of  the  disease ; 
and,  while  there  is  really  but  one  process  of  inflammation,  as  that 
process  is  often  interrupted,  prolonged,  or  modified  in  various  ways, 
its  products  must  necessarily  vary  greatly. 

Its  divers  grades  or  forms  are  distinguished  as  acute,  chronic, 
catarrhal,  interstitial,  suppurative,  croupous,  diphtheritic,  and  gon- 
orrhoeal. 

Before  entering  upon  the  consideration  of  cystitis  in  its  many 
forms,  I  desire  to  speak  of  hypersemia  and  h[emorrhage  of  the  blad- 
der. This  latter  affection  might  more  propei^y,  perhaps,  be  consid- 
ered under  another  head,  but  it  is  so  closely  connected  with  hyper- 
aemia  and  inflammation  that  I  prefer  to  treat  it  here. 

Hypersemia. — In  all  cases  the  first  perceptible  departure  from  the 
normal  is  a  derangement  of  circulation,  Hypernemia  of  the  mucous 
membrane  is  observed,  and  with  it  disorders  of  innervation,  as  is  evi- 
denced by  derangement  of  function  and  sensation. 


704  DISEASES   OF  WOMEN. 

In  hyperjpmiii  of  the  mucous  meinbrauc  of  tlie  bladder  the  blood- 
vessels are  distended,  and,  becoming  prominent  and  apj)arentl_y  more 
numerous,  give  to  it  a  bright-red  color.  The  arteries  are  the  first 
to  be  ati'ected.  If  the  hyperaemia  is  not  marked,  or  is  produced  by 
some  transient  cause  and  not  aggravated,  it  may  pass  off  in  a  shoi  r 
time,  and  leave  the  membrane  in  its  normal  condition.  If  it  is  of  a 
high  grade,  liowever,  rupture  of  some  of  tlie  vessels  may  occur,  the 
haemorrhage  taking  place  either  on  the  free  surface  of  the  membi'ane 
or  beneath  its  epithelial  layer.  Should  this  condition  continue,  the 
hyperajmia  which  began  in  the  arteries  extends  to  the  venous  side  of 
the  circulation,  and  the  vessels  become  more  prominently  and  uni- 
formly distended.  The  congestion  may  also  begin  on  the  venous 
and  extend  to  the  arterial  side,  as  in  sudden  interference  with  portal 
circulation.     As  a  rule,  however,  it  begins  in  the  ai'teries. 

A  clear  distinction  must  be  made  between  the  acute  congestion 
of  which  I  am  now  speaking,  and  which  is  chiefly  contined  to  the 
smaller  vessels,  and  passive  congestion  with  a  varicose  or  haemor- 
rhoidal  condition  of  the  veins  about  the  neck  of  the  bladder.  This 
hsemorrhoidal  condition  I  will  speak  of  later. 

Symptomatology. — The  symptoms  of  acute  congestion  of  the 
bladder,  as  a  rule,  occur  suddenly.  Frequent  but  painless  urination 
is  the  principal  symptom.  There  is  often  a  sense  of  heat  and  heavi- 
ness in  the  region  of  the  bladder,  which  is  greatly  aggravated  by 
standing  or  walking.  When  the  urethra  is  involved,  the  patient 
complains  that  the  mine  "scalds''  her. 

The  general  system  is  not  disturbed — i.  e.,  the  pulse  and  tempera- 
ture remain  normal.  The  physical  signs  are  mostly  negative.  The 
composition  of  the  urine  is  unchanged,  save  that  there  may  be  an 
excess  of  mucus  and  a  few  blood-globules  present.  There  may  be 
some  tenderness  on  pressure  over  the  bladder.  The  endoscoj^e  (when 
there  is  an  opportunity  to  use  it,  which  is  very  rare  in  this  trouble) 
shows  an  increased  redness  of  the  mucous  membrane,  with  occasion- 
ally an  excess  of  nuicus  on  its  surface. 

Diagnosis. — The  diagnosis  has  to  be  made  by  exclusion,  the  nat- 
ural history  of  the  affection  having  in  it  nothing  pathognomonic. 
It  is  liable  to  be  confounded  with  sympathetic  or  other  functional 
derangement  of  the  bladder,  caused  by  sudden  dislocations  of  the 
uterus  or  by  pelvic  inflammation,  such  as  pelvic  peritonitis  and  its 
results.  The  former  can  be  excluded  by  an  examination  of  the  ])el- 
^nQ,  organs,  and  the  latter  by  the  constitutional  symptoms  of  inflam- 
mation and  the  signs  of  such  pelvic  disease. 

Causes. — The  causes  of  hyperaemia  of  the  bladder  are  exposure 


ORGANIC   DISEASES   OF   THE    BLADDER.  705 

to  cold  ("especially  during  tlie  menstrual  jDeriod),  wetting  the  feet, 
overtaxation  in  walking  or  using  the  sewing-machine,  cxce>sive  vene- 
real indulgence,  constipation  of  the  bowels  from  torjjor  of  the  portal 
circulation,  the  excessive  use  of  stimulants,  and  the  use  of  improper 
articles  of  food. 

Treatment, — The  treatment  should  be  directed  to  equalizing  the 
circulation.  Diaphoretics,  warm,  stimulating  foot  baths,  hot  applica- 
tions over  the  epigastrium,  and,  above  all,  rest  in  the  recumbent 
position.  If  the  bowels  are  confined,  tbev  should  be  emptied  by 
saline  lax  itives.  AVhen  there  is  much  irritation  of  the  bladder,  caus- 
ing frequent  urination  and  vesical  tenesmus,  pulv.  doveri  with  cam- 
phor should  be  given,  or  su^^positories  of  belladonna  and  morphine 
introduced  into  the  vagina.  Under  this  treatment  the  trouble  will 
usually  pass  off  in  a  short  time.  It  may,  however,  go  on  to  the  de- 
velopment of  cystitis. 

Occasionally  bleeding  occurs  in  active  or  acute  congestion  of  the 
bladder,  and  that  leads  me  to  speak  of  heemorrhage  from  the 
bladder. 

Haemorrhage  from  the  Bladder. — Haemorrhage  from  the  bladder, 
or  (if  I  may  be  allowed  to  coin  a  word)  cystorrhagia,  is  usually  due 
to  some  important  disease  of  the  bladder,  and  is,  therefore,  rather  a 
symptom  than  a  disease.  For  this  reason  I  will  at  present  confine 
my  remarks  to  hagmorrhage  when  caused  by  acute  congestion,  which 
I  have  just  considered,  or  to  varicose  veins  of  the  bladder. 

The  bleeding  may  take  place  from  the  free  surface  of  the  mucous 
membrane,  and  mingle  at  once  with  the  urine  or  coagulate  in  the 
bladder.  It  may  also  take  place  beneath  the  surface  of  the  mucous 
membrane,  and  form  ecchymoses,  like  the  spots  seen  beneath  the 
skin  in  purpura.  We  may  also  have  a  condition  known  as  hsemo- 
globinuria,  in  which  only  the  coloring  matter  of  the  blood  is  found 
in  the  urine  ;  in  such  a  case  we  should,  of  coui^se,  find  no  blood-cor- 
puscles. 

The  quantity  of  blood  varies  greatly  in  different  diseases,  and  in 
the  same  disease  in  different  persons.  In  congestion  of  the  bladder 
blood- globules  will  often  be  foand  in  the  urine  only  on  microscopic 
examination,  while  at  other  times  the  urine  will  have  the  appeai'ance 
of  being  all  blood.  Again,  the  blood  may  coagulate,  and  be  passed 
in  clots,  or  the  coagula  may  remain  in  the  bladder,  finally  break 
down,  and  be  passed  as  a  chocolate-colored  or  blackish  matter. 

Symptomatology/. — The  symptoms  of  haemorrhage  do  not  differ 
from  those  of  congestion  or  the  onset  of  cystitis,  except  when  small 
clots  form,  distending  the  urethra,  and  causing  pain  in  urinating.  It 
46 


706  DISEASES   OF   WOMEX. 

is  very  rare  that  bleeding  from  these  causes  is  sufficient  to  prostrate 
the  patient. 

As  bleeding  may  take  place  at  any  ]>oint  in  tlie  urinary  tract,  it 
is  important  always  to  locate  the  luxMnorrhago.  When  coming  from 
the  bladder  in  any  quantity,  it  is  usually  jjassed  in  small  clots,  and 
is  seldom  so  intimately  mixed  with  the  urine  as  when  it  comes  from 
the  kidneys  or  ureters.  This  statement  is  not  exact,  and  at  best 
gives  but  a  probable  idea  of  the  true  facts.  To  complete  the  diag- 
nosis, we  must  resort  to  something  more  trustworthy.  Sir  Henry 
Thompson  gives  a  very  ingenious  method  for  determining  as  to 
whether  pus  found  in  the  urine  comes  from  the  kidneys  or  bladder, 
and  V^an  Buren  and  Keyes  advise  the  same  plan  for  detecting  the 
source  of  hsemorrhage. 

The  method  is  this:  "  A  soft  catheter  is  gently  introduced  first 
within  the  neck  of  the  bladder,  the  urine  drawn  olf,  and  the  cavity 
washed  out  very  gently  with  tepid  water.  If  the  water  can  not  be 
made  to  fl.ow  away  clear,  the  inference  is  that  the  blood  comes  from 
the  cavity  of  the  bladder.  If  it  will  flow  away  clear,  then  the  cath- 
eter is  closed  for  a  few  moments,  the  patient  being  at  rest,  and 
the  few  drachms  of  urine  which  collect  may  be  drawn  off  and  exam- 
ined. The  bladder  is  now  again  washed  out,  and  if,  after  a  single 
washing,  tlie  second  flow  of  injection  is  clear,  while  the  drachm  of 
urine  was  bloody,  the  inference  is  again  complete  that  the  blood 
comes  from  one  or  the  other  kidney." 

When  it  is  known  that  the  patient  has  had  no  Iddney-disease, 
nor  symptoms  of  renal  calculi,  the  endoscope  may  be  employed,  and 
possibly  the  bleeding-point  found.  This  has  been  done  with  the 
instrument  which  I  have  described,  but  one  may  fail  to  find  it  if  it 
be  high  up  laterally  or  antero-laterally,  or  be  covered  by  a  fold  of 
the  mucous  membrane. 

Hsemorrhage  from  the  urethra  might  mislead,  but  is  easily  de- 
tected if  it  is  remembered  that  in  this  case  bleeding  occurs  between 
the  acts  as  well  as  during  micturition.  It  may  also  readily  be  dis- 
covered with  the  endoscope,  provided  the  tube  be  not  too  large. 

Causation. — The  causes  of  vesical  haemorrhage,  or  cystorrhagia, 
are  numerous.  Congestion,  varicose  veins,  villous  cancer,  lesions  of 
structure,  as  in  ulceration  and  sloughing  of  nmcous  meml)rane  from 
injury  or  cystitis,  and  obstruction  to,  or  interference  with,  the  portal 
circulation.  This  may  possibly  explain  the  fact  that  haMuorrhage 
occasionally  occurs  in  those  suffering  from  malaria.  Perhaps  the 
vesical  haemorrhage  occurring  in  the  intense  heat  of  summer  in  the 
tropics  may  be  thus  explained.     In  malaria  the  obstruction  to  the 


ORGANIC  DISEASES   OF  THE   BLADDER.  707 

circulation  through  the  portal  system,  acting  as  a  predisposing  cause, 
the  intense  congestion  of  all  the  internal  organs  dnring  a  chill  or 
from  exposure  to  cold  would  certainly  tend  to  produce  cystorrhagia. 

In  purpura,  the  eruptive,  typhus,  and  typhoid  fevers,  bleeding 
from  the  bladder  may  occur ;  but,  as  it  is  there  secondary  to  the 
main  disease,  nothing  need  be  said  about  it  in  this  connection. 

The  most  marked  predisposing  cause  of  cystorrhagia  in  women 
is  a  tendency  to  the  haemorrhagic  diathesis,  so  connnon  among  chlo- 
rotic  females. 

Treatment. — The  treatment  must  largely  depend  on  the  cause. 
In  all  cases  rest  in  the  recumbent  position  should  be  insisted  on.  A 
large  number  of  haemostatics  have  been  recommended,  and  some  of 
them,  such  as  aromatic  sulphuric  acid,  tannic  and  gallic  acids,  in 
moderate  doses,  are  doubtless  of  some  value.  I  have,  however,  de- 
pended chiefly  on  doses  of  opium  sufiiciently  large  to  quiet  the  desire 
to  urinate,  and  alkaline  diluents  to  render  the  urine  non-irritant,  when 
it  was  found  to  be  excessively  acid. 

If  the  bleeding-point  or  points  can  be  discovered  with  the  endo- 
scope, applications  of  acetic  acid,  persulphate  of  iron,  or  nitrate  of 
silver  may  be  made.  Great  care  must  be  taken  in  using  these  reme- 
dies, lest  inflammation  and  ulceration  of  the  bladder  result.  Nitrate 
of  silver  and  strong  acetic  acid  are  more  to  be  feared  than  the  others. 

When  the  haemorrhage  is  so  free  as  to  excite  fears  of  prostration, 
ice  may  be  employed.  Small  smooth  pieces  should  be  introduced 
into  the  vagina  at  regular  intervals  as  long  as  the  patient  can  com- 
fortably bear  it.     Ice  may  also  be  applied  to  the  hypogastrium. 

When  the  blood  coagulates  and  forms  a  large  clot  in  the  bladder, 
it  should  be  allowed  to  remain  until  it  breaks  down  and  conies  away 
of  itself.  The  experience  of  surgeons  is  that  there  is  much  more 
danger  in  attempting  to  remove  the  clot  than  in  letting  it  alone. 
There  are  two  dangers  in  removing  coagula  from  the  bladder.  One 
is,  that  doing  so  will  almost  certainly  start  the  bleeding  again ;  and 
the  other  is  liability  to  injure  the  bladder,  and  cause  inflammation. 
Let  the  clots  take  care  of  themselves,  keeping  the  patient  quiet  and 
comfortable  (with  opium,  if  necessary)  until  the  coagula  are  disposed 
of.  Lime-water  has  been  recommended  as  a  solvent  of  blood-clots 
by  Dr.  J.  H.  Ledlin,  of  Pittsfield,  Illinois,  and,  in  the  case  reported 
by  him,  and  which  is  narrated  with  the  cases  of  hasmorrhage  in  this 
chapter,  seems  to  have  acted  well. 

In  one  case  of  traumatic  vesical  haemorrhage  that  came  under 
my  care,  a  large  clot  formed  in  the  bladder,  and  urination  was  com- 
pletely arrested.     I  was  unable  to  determine  whether  the  inability 


708  DISEASES  OF   ^\•OMEN. 

to  urinate  was  due  to  tlie  i)resence  of  the  clot  or  to  loss  of  contractiU; 
power  of  the  vesical  walls  from  the  injury.  The  patient  suffered  »• 
much,  however,  from  the  pain  caused  by  retention  that  I  was  obliL''«il 
to  use  the  catheter.  I  ein})l(n'ed  the  tiexible  instrument  of  Ja(pU's, 
and,  by  carefully  worming  it  in  past  the  clot,  I  sncceeded  from  time 
to  time  in  drawing  off  enough  of  the  urine  and  broken-down  clot  t<> 
relieve  the  lady  until  she  was  able  to  reheve  herself.  I  was  careful 
not  to  disturb  the  clot. 

Allusion  has  been  made  to  varicose  veins  of  the  bladder,  called 
by  some  hiemorrhoids  of  the  bladder.  This  condition  is  chiefly 
found  in  pregnant  women,  especially  those  who  have  borne  several 
childi'en.  The  cause  is  interrujition  of  the  venous  circulation  by 
pressure  of  the  gravid  uterus.  The  veins  of  the  anterior  vaginal 
wall,  introitus  vulvse,  and  labia,  will  often  be  found  in  the  same 
condition.     Occasionally  prolapsus  of  the  bladder  ^^^ll  also  be  found. 

This  affection  gives  rise  to  tliose  symptoms  of  pelvic  distress  and 
frequent  urination  that  are  so  troublesome  in  some  pregnant  women. 
It  must  be  kept  in  mind,  however,  that  the  same  symptoms  may 
come  from  pressure  which  does  not  produce  varicose  veins. 

If  it  is  found  that  the  patient  feels  relieved  to  some  extent  in 
the  recumbent  position,  and  the  urine  is  normal,  this  troul)le  may 
be  suspected,  and,  if  the  symptoms  are  sufficiently  urgent,  a  local 
examination  should  be  made,  which  will  re\'eal  a  varicose  condition 
of  the  vessels  of  the  urethra  and  vaginal  walls,  and  from  this  it  may 
be  inferred  that  the  same  condition  exists  in  the  bladder. 

If  the  diagnosis  is  still  doubtful,  the  endoscope  will  aid  in  settling 
the  question. 

This  affection  is  relieved  or  passes  off  altogether  after  confine- 
ment, and  the  best  that  can  be  done  usually  is  to  give  rest  and  try 
to  make  the  patient  comfortable  until  the  end  of  her  "  term." 

Should  the  trouble  continue  after  delivery,  especially  if  there  is 
cystocele  or  prolapsus  of  the  bladder,  much  good  may  be  done  by 
restoring  and  keeping  the  organ  in  place.  This  can  best  be  accom- 
plished by  using  the  cotton  pessary  or  a  roll  of  marine  lint  packed 
loosely  into  the  vagina,  like  a  tampon.  The  patient  can  be  instructed 
to  use  this  herself.  Attention  should  be  given  to  the  general  healtli, 
and  particularly  to  the  condition  of  the  bowels  and  portal  circulation. 
Kest  in  bed,  and  the  use  of  cool  water  as  a  vaginal  injection,  may 
also  be  of  use. 

Should  ha3morrhage  occur  from  this  condition  of  the  veins,  it 
may  be  treated  as  described  in  the  discussion  of  that  subject. 


ORGANIC   DISEASES   OF   THE    BLADDER.  709 


ILLUSTRATIVE    CASES. 

Case  of  Hsemorrhage  of  the  Bladder ;  Blood-clots  dissolved  by  Lime- 
water. — J.  II.  Letllin,  M.  D.,  Pittsfield,  Illinois,  in  a  letter  to  the 
'•'  Medical  Record,"  November  8, 1879,  says  :  I  have  a  patient,  a  man 
who  for  years  has  siLffered  greatly  from  hsematuria.  The  blood 
comes  from  the  kidneys.  At  times  the  haemorrhage  is  very  profuse, 
and  clots  the  bladder.  Heretofore  I  have  always  succeeded  in  wash- 
ing it  out  with  a  double  current  catheter.  Last  Saturday  I  was  called 
to  see  him.  He  had  lost  a  great  quantity  of  blood,  and  was  suffering 
very  much  from  vesical  tenesmus  ;  I  passed  my  catheter,  and  injected 
a  stream  of  water.  All  at  once  the  stream,  returning,  would  stop. 
By  withdrawing  the  instrument  I  could  start  it  again,  but  he  insisted 
there  was  a  foreign  body  in  there.  I  must  say  that  the  previous  day 
he  had  experienced  excruciating  pain  along  the  course  of  the  ureter; 
I  suspected  stone,  and  sounded  him,  but  could  not  discover  one ; 
still,  my  instrument  touched  something ;  I  repeated  the  washing  out 
of  the  bladder  until  the  water  returned  colorless.  I  then  made  up 
my  mind  that  there  was  a  clot,  with  the  coloring  matter  washed  out, 
and,  recollecting  your  account  of  dissolving  the  false  membrane  with 
lime-water,  I  threw  in  one  half  pint  of  lime-water,  allowing  it  to 
remain  half  an  hour.  When  it  passed  off  it  resembled  what  you 
describe  as  the  appearance  of  the  false  membrane  after  lying  in  lime- 
water.  He  also  passed  a  large  piece  of  fibrin,  which  had  evidently 
been  acted  on  by  lime-water,  although  not  sufficiently  to  dissolve  it 
entirely.  Had  it  not  passed  away,  I  am  convinced  another  injection 
would  have  dissolved  it  entirely.  He  is  now  quite  comfortable,  all 
sense  of  a  foreign  body  in  the  bladder  having  passed  away. 

Haemorrhage  from  the  Bladder  due  to  Malarial  Influence. — This 
patient  was  a  lady  of  twenty-one,  married  two  years,  never  pregnant, 
and  of  a  slightly  strumous  constitution.  For  several  days  she  had  to 
urinate  more  frequently  that  usual.  She  then  began  to  be  restless  at 
night.  These  symptoms  developed  into  well-marked  fever  in  the 
afternoon  and  first  part  of  the  night.  With  this  came  frequent  urin- 
ation, with  pain  and  haemorrhage  from  the  bladder.  The  blood 
came  from  the  neck  of  the  bladder  evidently,  from  the  fact  that  it 
was  mixed  with  the  urine,  but  was  dark  in  color,  as  it  would  have 
been  if  from  the  kidneys.  There  was  no  blood  passed  after  the 
bladder  was  empty,  as  would  have  been  the  case  if  it  came  from  the 
urethra. 

The  temperature  was  103°  F.  in  the  evening ;  normal  in  the 
morning.     This  continued  for  two  weeks,  at  which  time  I  gave  qui- 


710  DISEASES   OF   WOMEN. 

nine,  gr,  x,  in  tlio  morning.  After  the  quinia,  tlie  fever  and  bleed- 
ing st<)i)ped,  and  did  not  return.  Slie  was  for  over  a  year  well,  tlien 
lier  tr(Hible  returned — that  is,  she  had  painful  urination  without  haem- 
ori'hage.  I  found  the  cause  to  be  a  polypoid  growth,  which  looked 
like  a  wart,  in  the  anteiior  wall  of  the  urethra  near  the  meatus.  I 
removed  it  by  snare,  with  the  result  of  relieving  her  completely. 


CYSTITIS. 

This  is  a  disease  that  is  much  more  common  among  women  than 
is  generally  supposed.  It  is  necessary,  therefore,  to  infjuire  carefully 
into  the  etiology,  pathology,  and  therapeutics  of  this  aliection,  which 
causes  great  suffering  on  the  part  of  the  patient,  and  taxes  the  high- 
est skill  of  the  ablest  surg^eons. 

To  the  several  forms,  grades,  or  degrees  of  tliis  disease  various 
names  have  been  given,  such  as  acute,  subacute,  and  chronic  cystitis, 
cystitis  mucosa  (catarrh  of  the  bladder),  interstitial  cystitis,  peri-  and 
epi-cystitis,  croupous,  diphtheritic,  and  gonorrhoeal  cystitis.  This 
medley  of  names  should  not  be  allowed  to  lead  to  confusion,  but 
this  fact  should  be  firmly  fixed  in  the  mind,  that,  with  the  exception 
of  the  last  three  (the  etiology  and  pathology  of  whi-jh  are  somewhat 
different),  they  are  all  simply  steps  or  stages  in  one  general  process. 
Thus  a  patient  may  have  received  an  injury  of  the  bladder  by  the 
use  of  a  catheter,  causing  an  acute  cystitis.  This  may  end  in  con- 
valescence, or  merge  slowly  into  the  more  chronic  form,  having  very 
likely  as  an  inteniiediate  step  catarrhal  cystitis.  This,  too,  may  go 
on  to  recovery  ;  but,  if  tlie  process  extends,  and  its  severity  increases, 
ulceration  takes  place,  and  the  submucous  and  intermuscular  tissues 
become  involved,  producing  interstitial  cystitis.  If  the  intiammation 
extends  still  further,  and  involves  the  serous  coat  of  the  bladder, 
either  by  extension  or  ulceration,  with  or  without  perforation,  we 
shall  have  peri-  or  epi-cystitis.  In  this  example  I  hope  I  have  made 
clear  the  fact  that  names  are  only  given  to  denote  the  degree  of  in- 
tensity of  the  inflammatory  process,  and  the  character  and  extent  of 
the  tissue  involved. 

Inflammation  of  the  mucous  membrane  alone  is  by  far  the  most 
common  form,  and  hence,  in  using  the  term  cystitis,  reference  is 
usually  made  to  inflammation  of  that  membrane  only.  When  other 
tissues  are  involved,  or  the  character  of  the  disease  is  peculiar,  some 
qualifying  word  is  added  to  distinguish  it. 

Acute  inflammation  of  the  bladder,  other  than  that  due  to  local 
causes,  is  emphatically  denied  an  existence  by  many  authors.     The 


I 


ORGANIC   DISEASES   OF   TUE   BLADDER.  711 

stateinents  made  are  usually  too  l)road  and  sweopiiicf  to  be  sustained 
by  tlie  facts  observed  in  actual  practice.  1  am  inclined  to  believe 
that  cases  of  acute  cystitis  from  exposure  to  cold  and  wet  do  occur. 
It  must,  liowever,  be  admitted  that  such  cases  are  very  rare,  and 
some  that  have  been  considered  as  acute  idiopathic  cystitis  may  have 
been  but  a  development  of  acute  inflammatory  disease  upon  a  pre- 
existing abnormal  condition. 

It  is  also  possible  that  those  wbo  deny  the  existence  of  acute  idio- 
pathic cystitis  may  base  their  belief  upon  the  fact  that  in  what  is 
called  acute  inflammation  of  the  bladder  all  the  phenomena  of  well- 
detined  inflammation  are  not  23resent,  while  others  consider  hyper- 
;vmia  of  the  mucous  membrane  and  derangement  of  bladder  function 
all  that  is  necessary  to  constitute  cystitis.  Thus  the  aj^parently  dif- 
ferent opinions  that  exist  among  authors  upon  this  subject  may  arise 
from  conflicting  views  as  to  what  really  constitutes  inflammation. 

I  prefer  to  class  this  condition  (of  congestion,  hypersecretion  of 
mucus,  abnormal  exfoliation  of  epithelium,  and  irritability)  among 
the  inflammatory  aifections,  and  call  it  acute  cystitis.  Such  an  affec- 
tion as  this  is  met  with  in  every-day  practice,  and  I  know  of  no  bet- 
ter name  for  it. 

With  this  understanding,  then,  I  will  pass  to  a  discussion  of 
acute  cystitis. 

Pathology . — As  acute  cystitis  soon  terminates  in  resolution,  or 
merges  gradually  into  chronic  cystitis,  I  think  it  best  to  give  the 
pathology  of  both  diseases  at  once,  they  being,  as  I  have  already  said, 
simply  different  in  degree  of  intensity  and  duration. 

The  morbid  anatomy  of  cystitis  is  the  same  as  that  of  inflamma- 
tion of  mucous  membranes  in  other  parts  of  the  body.  In  the  more 
acute  forms  the  membrane  is  swollen  and  relaxed,  and  of  a  bright 
or  deep  red  color,  from  hyper^emia.  The  surface  is  partially  or  en- 
tirely covered  with  a  thick,  tenacious  mucus.  There  is  exfoliation 
of  the  epithelium,  as  shown  by  the  partially  denuded  condition  of 
the  membrane,  especially  at  the  top  of  the  rugae,  and  pus  and 
loose  cells  are  found  in  the  sulci  between  the  folds. 

In  some  instances,  especially  in  cases  of  acute  cystitis  caused  by 
extreme  overdistention  due  to  mechanical  or  other  retention,  there 
may  occur  a  throwing  off"  of  the  whole  or  only  a  part  of  the  mucous 
membrane  of  the  bladder.  This  is  more  apt  to  occur  when  the  re- 
tention and  overdistention  are  caused  by  various  accidents  of  the 
puerperal  state  or  during  delivery.  That  the  separation  of  the 
mucous  membrane  is  not  due  to  direct  injury  caused  by  the  child's 
head  or  instruments  carelessly  used,  but  to  the  effect  of  overdisten- 


712  DISEASES  OF   WOMEN. 

tion,  is  shown  by  the  fact  that  the  vesical  neck,  w  hicli  is  subject  to 
the  most  direct  injury,  seldom  shows  separation  of  its  mucous  mem- 
brane. That  injury  to  the  organ  may  predispose  to  separation,  or 
even  determine  it  when  already  predisposed  to  it  by  sumo  other 
cause,  there  can  be  no  doubt.  Most  of  these  cases  of  separation  of 
the  mucous  membrane  have  occurred  in  women,  and  almost  all  fol- 
lowed delivery.  The  bladder  which  has  participated  in  the  general 
congestion  of  the  pelvic  organs  incident  to  the  puerperal  state  is  in 
aTi  excellent  condition  to  allow  such  separation  to  take  j)lace. 

The  manner  of  its  production  is  probably  as  follows :  A  woman 
at  full  term  is  delivered  after  a  long  and  tedious  labor,  with  or  with- 
out the  use  of  instruments,  of  a  healthy  child.  The  child's  head  or 
the  forceps  may  have  done  violence  to  the  urethral  mucous  mem- 
brane by  crowding  the  urethra  against  the  unyielding  pubic  bones. 
Swelling  of  the  mucous  membrane  results,  and  retention  of  urine 
(if  the  patient  be  not  relieved  by  the  catheter^  follows  and  persists 
for  a  varying  length  of  time.  The  doctor,  the  nurse,  and  the  pa- 
tient herself  are  often  led  to  believe,  from  the  constant  or  inter- 
mittent dribbling  of  urine,  that  there  is  an  irritable  condition  of 
that  organ,  with  frequent  urination.  The  truth  is,  that  this  drib- 
bling (stillicidium)  is  almost  a  certain  sign  of  an  overfilled  bladder, 
aud  if  the  patient  be  not  relieved  the  distention  will  gradually  in- 
crease. The  organ  having  reached  its  limit  of  distention,  or  being 
stretched  to  its  utmost,  tlie  pressure  within  is  so  great  as  to  cut  off 
the  supply  of  blood  to  the  submucous  tissue,  and  thus  to  the  mu- 
cous membrane  itself.  This  is  more  readily  accomplished,  as  the 
muscular  fibers  are  pulled  apart  and  the  mucous  membrane  thereby 
allowed  a  certain  amount  of  bulging,  by  which  its  blood-supi)ly  is 
seriously  interfered  with.  If  the  distention  be  relieved  early 
enough,  nothing  worse  than  an  acute  cystitis  results ;  but  if  not  re- 
lieved, partial  or  total  death  of  the  membrane  occurs,  and  it  is 
sooner  or  later  thrown  off.  Although  death  of  the  membrane  may 
not  take  place  in  every  case,  or  in  one  half  of  the  cases  of  overdis- 
tention,  it  is  no  argument  against  this  method  of  its  production. 
Nor  yet  is  it  an  argument  in  favor  of  the  idea  that  it  is  caused  by 
instrumental  \aolence  to  the  body  as  well  as  the  neck  of  the  viscus ; 
for  that  the  latter  can  not  be  the  only  cause  may  be  seen  from  the 
fact  that  it  has  occuiTed  in  the  male  (Liston  per  Barnes).  It  is 
probable  that  there  are  several  causes,  and  that  these  may  work  to- 
gether to  produce  the  result.  From  the  uniform  exfoliation  it 
would  look,  however,  as  if  the  most  important  cause  was  a  uniform 
pressure  cutting  off  the  blood-supply,  and  thus  causing  death  of  the 


ORGANIC   DISEASES   OF  THE   BLADDER.  713 

part.  It  is  even  to  be  conceived  that  where  marked  iiijurv  ha«  heen 
done  the  membrane  by  overdistention  (though  not  sntK<'ient  in  it- 
self to  cause  death),  too  rapid  relief  of  retention  causing  congestion, 
irritation  by  catheter,  peculiar  systemic  conditions,  and  the  intense 
inilanmaation  which  follows  may  finish  the  work.  viz. :  fully  carrv 
out  the  impression  already  made  by  the  overdistention. 

This  affection  is  not  a  common  one,  and  though  cases  may  sel- 
dom be  met  1  desire  to  lay  stress  upon  the  great  importance  of  jxiv- 
ing  strict  and  individual  attention  to  the  condition  of  the  uriruiry 
organs  in  pregnant  and  parturient  w^omen.  The  catheter  can  tell 
more  of  the  condition  of  the  patient's  bladder  in  such  cases  than  any 
nurse,  and  can  do  no  harm  whatever  when  a  soft  instrument  is  used 
with  care. 

Experiments  on  dogs  have  proved  that  the  detachment  of  the 
membrane  begins  at  that  part  of  the  bladder  just  op])osite  the  vesi- 
cal neck.  At  this  point  the  membrane  bulges  out  with  a  collection 
of  blood  and  serum  beneath  it,  and  this  bulging  gradually  extends 
to  other  parts.  Meantime,  in  the  bladder,  the  mucus  poured  out 
to  shield  the  membrane  causes  the  urine  to  decompose,  and  incrusta- 
tions of  amorphous  and  triple  phosphates  are  found  on  the  surface 
of  the  exfoliated  membrane.  The  color  of  the  mucous  membrane  is 
usually  either  a  deep  red,  greenish  red,  or  black,  and  it  may  come  away 
either  in  pieces  or  as  a  whole.  In  some  cases  (Mr.  Wells's  second 
case,  Barnes)  part  of  the  muscular  as  well  as  the  mucous  tissue 
sloughed  off  and  came  away.  In  Mr.  Liston's  case  the  entire 
mucous  membrane  came  away  through  a  supra-pubic  opening  made 
by  that  gentleman  to  relieve  retention.  This  occurred  in  the  case 
of  a  male  adult. 

Some  of  these  patients  have  recovered,  and  it  is  believed  by 
Schatz  that  the  reproduction  of  the  membrane  commences  at  that 
portion  of  it  always  left  at  the  vesical  neck. 

That  the  completion  of  the  sloughing  does  not  takes  place  until 
sometime  after  the  injury  is  done,  and  that  the  membrane  itself  may 
block  the  urethra  and  cause  further  retention,  is  illustrated  by  the 
following  case,  taken  from  Barnes's  able  lecture  in  the  "  Lancet." 
January  2,  1875.  The  case  was  under  the  care  of  Dr.  Wardfll, 
at  the  Infirmary,  Tunbridge  Wells.  "  A  woman  was  admitted 
with  retention  of  urine.  Fetid  urine  was  drawn  off.  A  fn-tus 
of  three  or  four  months  was  expelled  followed  by  its  placentii. 
Then  incontinence  ensued.  The  urine  was  still  offensive,  and 
loaded  with  mucus.  Twelve  days  later  she  was  seized  with  great 
pain  over  the  pubic  region.     Next  morning  the  house  surgeon  was 


714  DISEASES  OF  WOMEN. 

called  to  see  her  on  account  of  excessive  pain.  lie  felt  a  substance 
being  expelled,  and  saw  a  mass  protruding  through  the  meatus  uri- 
narius.  This  was  expelled  in  half  an  hour.  At  the  moment  of  ex- 
jHilsion  the  urine  gushed  out  in  great  force  and  in  large  quantity. 
Instant  relief  followed,  and  she  perfectly  recovered,  Tlie  substance 
looked  as  if  it  were  the  whole  mucous  coat  of  the  bladder.  Its 
inner  surface  was  coated  with  gritty  deposits.  Its  minute  structure 
is  not  described."  Barnes  has  no  doubt  but  that  the  retention  was 
in  this  case  caused  by  retroversion  of  the  gravid  uterus. 

One  of  ]\Ir.  Spencer  Wells's  cases,  also  cited  by  Barnes  {loc.  cit), 
is  very  instructive  :  "  A  woman,  aged  22,  had  a  natural  labor  with 
her  lirst  child.  The  bladder  was  not  emptied  for  sixty-two  hours. 
Five  pints  of  turbid,  bloody  urine  were  then  drawn  off.  Cystitis  fol- 
lowed, then  incontinence  of  urine,  and  a  train  of  distressing  cerebral 
symptoms,  ending  in  death  two  months  after  delivery.  The  bladder 
after  death  was  found  to  contain  a  detached  cast,  lying  loose,  cov^- 
ered  wdth  gritty  dejDOsits  of  urates  and  phosphates.  The  walls  of 
the  bladder  were  thick  and  contracted,  the  muscular  iibers  being 
distinctly  visible.  The  cast  resembled  degenerated  epithelium. 
On  boiling  a  piece  of  it  in  dilute  acetic  acid,  much  of  the  saline 
matter  became  dissolved,  and  some  of  the  tissue  became  clear,  look- 
ing like  smooth  muscular  tissue  which  had  begun  to  degenerate,  as 
shown  by  the  deposit  of  fatty  or  albuminous  particles  in  its  sub- 
stance." 

Further  pathological  results  may  follow  the  prolonged  retention 
of  urine.  The  bladder  having  reached  a  certain  point  where  no 
more  ui-ine  can  enter  it,  and  even  before  this  time,  the  ureters  are 
filled  from  the  urine  above,  and  as  the  renal  pelves  till,  both  they 
and  the  ureters  are  put  greatly  on  the  stretch.  The  kidneys  con- 
tinue to  secrete  urine  until  the  pressure  in  the  urinary  tubules  equals 
that  of  the  blood  in  the  glomerulus.  At  that  point  all  secretion 
ceases,  and  pressure  on  the  emulgent  veins  becomes  so  great  that  de- 
generative changes  are  apt  to  take  ]')lace.  In  some  cases  after  the 
pressure  is  relieved,  acute  uei)hritis  results.  The  urine  folh)wing 
such  a  condition  of  distention  is  loaded  with  hyaline,  granular,  and 
epithelial  casts,  and  epithelial  elements  from  the  kidneys. 

The  following  case,  which  occurred  in  the  practice  of  Dr.  Geo. 
W.  Gushing,  of  this  city  (the  doctor  having  kindly  furnished  me 
with  a  report  of  it),  may  serve  as  an  illustration  of  what  I  have  been 
saying : 

"  Mrs.  S.,  of  New  York,  aged  twenty-six  ;  married  eight  years  ; 
one  child  ;  catamenia  regular ;  appetite  fair  ;  bowels  sluggish  ;  no 


ORGANIC   DISEASES  OF  THE   BLADDER.  715 

dysuria  previous  to  present  attack.  Has  been  under  treatment  for 
the  past  two  months  for  cervical  endometritis.  Local  applications  of 
mild  astringents  and  glycerin,  with  injections  of  borax.  Tonics 
and  laxatives  internally.  Theie  being  some  tendency  to  tubercu- 
losis, slie  was  given  cod-liver  oil. 

"I  was  called  to  see  this  patient  May  29,  187Y.  She  told  me 
she  was  suli'ering  from  internal  haemorrhoids,  and  that  the  rectal 
tenesmus  was  very  distressing.  She  had  had  similar  attacks  before, 
and  seemed  to  have  no  doubt  as  to  what  the  trouble  was.  As  she 
was  menstruating  I  made  no  examination,  but  advised  rest  and  a 
laxative  powder,  to  be  followed  by  morphia  suppositories. 

"  May  30. — Bowels  moved  since  last  visit  with  considerable 
pain.  Complained  of  some  vesical  irritation,  but  had  passed  urine. 
Not  much  relief. 

''''May  31st. — No  better.  An  examination  showed  no  haemor- 
rhoids. Menses  ceased.  Vaginal  examination  revealed  a  very  sensi- 
tive spot,  with  hardening  on  the  right  side,  between  the  rectum  and 
vagina.  Pulse  and  temperature  slightly  elevated.  Vesical  and  rec- 
tal tenesmus,  but  no  trouble  in  passing  water.  Made  diagnosis  of 
probable  pelvic  abscess.  Advised  poultices  to  the  perinaeum,  warm 
applications  over  the  abdomen,  and  gave  anodynes.  Patient  much 
relieved  by  the  treatment,  but  still  having  severe  pelvic  distress. 

"  June  ^d. — Condition  the  same. 

'■'June  3d. — Found  the  vesical  distress  increased.  Her  husband 
said  that  she  had  passed  urine  during  the  night.  Was  called  to  her 
in  the  afternoon,  and  found  her  in  great  suffering.  Said  that  her 
husband  had  misinformed  me,  and  that  she  had  passed  no  urine  for 
about  thirty  hours.  I  examined  the  abdomen,  and  found  dullness 
well  up  to  the  umbilicus.  Introducing  a  catheter,  I  drew  off  a  large 
(piantity  of  very  offensive,  high-colored  urine,  with  much  relief  to 
the  patient.  For  the  next  two  days  I  was  obliged  to  use  the  cath- 
eter. An  examination  of  the  urine  drawn  off  was  made,  and  showed 
the  presence  of  renal  epithelium,  granular,  hyaline,  and  epithelial 
casts,  and  considerable  albumen,  as  also  epithelium  from  the  bladder 
and  ureters. 

'"'•  June  5th. — I  found  a  tendency  of  the  inflammatory  products 
in  the  pelvis  to  point  about  the  center  of  the  perinaeum,  and,  though 
not  quite  sure  of  pus,  I  punctured  and  evacuated  quite  a  large  amount 
of  it. 

"  Since  then  the  treatment  has  been  the  use  of  alkalies  and  sooth- 
ing drinks — tr.  ferri  cliloridi — and  washing  out  the  bladder  with 
lukewarm  water  containing  salt  and  a  little  carbolic  acid.     The  ab- 


71G  DISEASES  OF   WOMEN. 

scess  remainiiif^  open  and  very  sluggish  for  some  time,  I  put  the 
patient  under  ether,  and  performed  the  operation  for  fistula  in  ano. 
At  the  present  writing,  October  30th,  Mrs.  S.  is  in  excellent  condi- 
tion, having  gained  in  tlesli  and  strength,  and  being  no  longer  trou- 
bled with  the  vesical  disoi-der." 

This  case  is  not  only  interesting  as  showing  the  serious  changes 
that  may  occur  in  the  kidneys  from  vesical  distention,  but  as  illus- 
tratiner  the  occurrence  of  retention  of  urine  from  reflex  nei*vou8  in- 
fluence.  Abscesses  about  the  rectum  are  esjieeially  prone  to  cause 
retention.  Although  in  this  case  the  mischief  done  to  the  kidneys 
was  soon  corrected,  it  does  not  follow  that  it  will  be  so  readily 
accomplished  in  all  cases,  especially  if  the  retention  continues  un- 
relieved for  any  length  of  time. 

CHRONIC   CYSTITIS. 

Pathology. — In  chronic  cystitis  the  redness  of  acute  inflamma- 
tion gradually  gives  way  to  a  muddy  gray  color,  the  membrane  being 
smeared  in  places  with  a  dark  yellow  muco-purulent  secretion.  As 
the  disease  advances,  there  is  excessive  cell  growth  on  the  free  mu- 
cous surface.  Patches  of  ulceration  appear  here  and  there,  attended 
with  the  formation  of  pus  and  occasional,  though  usually  slight, 
haemorrhages.  Sometimes,  at  the  portions  destroyed  by  ulceration, 
the  process  of  hyperplasia  is  established,  and  a  polypoid  material  is 
developed.  This  has  the  appearance  of  exuberant  granulations,  as 
seen  on  a  healing  sore.  At  other  times,  and  even  in  portions  of  the 
same  organ  in  which  hyperplasia  occurs,  the  process  of  ulceration 
advances.  The  submucous  intermuscular  tissue  partakes  of  the 
inflammatory  trouble,  and  thickening  of  the  vesical  walls  results. 
The  decomposed  urine,  mixed  with  pus,  mucus,  blood,  and  shreds 
of  membrane,  forming  the  chocolate-colored  fluid  found  in  the 
advanced  stages  of  this  disease,  acts  as  an  irritant  on  the  unhealthy 
membrane,  and  produces  deeper  or  fresh  ulceration. 

In  advanced  cases,  with  deep  ulceration,  the  muscular  flbers 
(which  resist  the  destructive  processes  longest)  are  occasionally  seen, 
stretching  from  one  side  of  an  ulcer  to  the  other,  forming  a  sort  of 
bridge.  "When  the  end  of  one  of  these  Hbers  becomes  detaciied,  it 
floats  like  a  filament  in  the  contents  of  the  bladder.  In  some  cases 
the  salts  of  the  urine  are  deposited,  and  form  incrustations  on  the 
ragged  mucous  membrane. 

I  remember  that  one  of  my  patients  frequently  passed  lumps  of 
material  that  on  examination  proved  to  consist  of  all  these  products 


ORGANIC  DISEASES  OF  THE  BLADDER.  Y17 

of*  destructive  inflammation,  among  which  were  mixed  deposits  of 
tlie  urinary  .salts  in  the  form  of  hard,  gritty  pnrticles. 

In  cases  of  long-  stamling,  the  vesical  ends  of  the  ureters  are 
obstructed  by  swelling  and  hypertrophy  of  the  bladder-walls.  This 
jiroduces  obstruction  to  the  free  flow  of  urine,  and  leads  to  dilatation 
of  the  ureters  and  renal  pelves,  and  in  some  cases  organic  disease  of 
the  kidneys  follows  in  the  train  of  pathological  sequences.  I  will 
refer  to  this  subject  again. 

When  the  disease  has  destroyed  the  mucous  membrane  partially 
or  wholly,  and  extends  to  the  muscular  parietes,  we  have  what  is 
known  as  interstitial  cystitis,  and,  if  the  serous  coat  becomes  in- 
volved, there  is  also  pericystitis.  This  latter  is  simply  an  inflam- 
mation of  that  portion  of  the  pelvic  peritonaeum  which  covers  the 
bladder.  In  interstitial  cystitis,  after  destruction  of  portions  of  the 
mucous  membrane  by  ulceration,  the  areolar  tissue  beneath  it  and  in 
the  muscular  walls  gives  way,  the  muscular  tiber  generally  becomes 
thickened  and  burrowed  by  ulcerated  cavities,  irregular  in  form,  and 
surrounded  by  cicatricial  tissue.  The  extreme  hypertrophy  of  the 
muscular  coat  found  in  the  bladder  of  the  male  under  these  circum- 
stances does  not  so  commonly  exist  in  that  of  the  female. 

In  epi-  or  peri-cystitis  the  peritoneal  coat  is  found  to  be  hyper- 
semic  and  thickened  by  exudation,  and  the  adhesions  which  follow 
bind  together  the  bladder  and  the  neighboring  organs.  Perforation 
of  the  pentonseum  sometimes  occurs,  allowing  infiltration  of  the 
urine.  This  usually  develops  general  peritonitis  or  septicaemia,  or 
both,  and  death  almost  inevitably  follows. 

I  have  already  stated  that  the  walls  of  the  bladder,  including  the 
serous  coat,  may  become  involved  by  the  extension  of  a  primary 
inflammation  of  the  mucous  membrane.  This  is  undoubtedly  the 
usual  mode  of  occurrence,  but,  in  some  cases,  I  think  that  all  of  the 
bladder  coats  may  become  inflamed  at  the  same  time,  making  an 
inflammation  in  toto.  At  least,  it  is  a  fact  that  in  some  cases  the 
mucous,  muscular,  and  serous  layers  of  the  organ  in  question  become 
involved  in  such  rapid  succession  as  to  prevent  us  from  detecting  its 
progress  from  one  tissue  to  another. 

The  inflammatory  process,  having  traversed  the  mucous  and  nms- 
cular  coats,  and  involved  the  serous,  especially  where  ulceration  of 
the  mucous  membrane  accompanies  it,  is  likely  to  extend  to  the 
other  portions  of  the  pelvic  peritonaeum  and  cellular  tissue  if  the 
patient  lives  sufficiently  long. 

It  will  be  observed  that  in  this  condition  there  is  about  the  same 
pathological  anatomy  as  in  pelvic  peritonitis  and  cellulitis  where  in- 


718  DISEASES   OF    WOMEN. 

flammation  of  the  bladder- walls  is  caused  by,  and  consequently  sec- 
ondary to,  the  pelvic  inflammation.  In  such  condition  the  kidneys 
and  ureters  are  usually  found  diseased.  In  some  cases  the  cellular 
tissue  about  the  bladder  becomes  greatly  increased,  and  occasionally 
abscesses  form,  as  in  ordinary  pelvic  cellulitis. 

I  am  satisfied  that  the  disease  described  in  some  of  the  text-books 
as  idiopathic  pericystitis  is,  in  almost  all  cases,  when  it  occurs  in 
women,  a  pelvic  peritonitis  originally,  the  bladder  becoming  affected 
secondarily. 

One  of  the  most  serious  results  of  intense  vesical  inflammation 
is  gangrene.  The  bladder  becomes  distended  from  paralysis  of  it3 
muscular  walls,  and  its  contents  are  found  to  be  a  brownisli  colored 
fluid,  consisting  of  decomposed  urine,  shreds  of  broken-down  nmcous 
membrane,  altered  blood,  pus,  epithelial  elements,  and  urinary  salts. 
The  mucous  membrane  is  found  to  be  soft,  pultaceous,  and  altered 
in  color,  the  latter  varying  fi'om  a  deep,  charred  black  to  a  dark 
greenish  or  greenish  yellow. 

The  submucous  connective-tissue  layer  and  the  muscular  coat  are 
softened,  discolored,  and  infiltrated  ^\^th  malodorous  pus.  The  peri- 
tonaeum is  also  injected,  and  in  places  discolored,  sometimes  per- 
forated, and  having  undergone  fatty  degeneration.  This  complica- 
tion usually  occurs  in  the  course  of  chronic  cystitis  with  considerable 
ulceration,  and  in  which  an  acute  inflammation  is  lighted  up, 
there  not  being  sufficient  vitality  left  to  prevent  rapid  and  deep 
gangrene. 

These  extreme  forms  of  cystitis  are  rare,  and  occur  generally  in 
connection  with  abnormal  cases  of  lal)or,  A  pregnant  woman  having 
a  cystitis  of  a  mild  form  is  liable  to  develop  acute  general  cystitis 
at  her  confinement.  Again,  inflammation  and  gangrene  of  the  blad- 
der sometimes  follow  instrumental  or  manual  delivery  in  which 
severe  contusions  of  the  bladder  have  occurred. 

I  desire  now  to  call  attention  to  some  of  the  effects  of  cystitis  on 
the  ureters  and  kidneys.  That  form  of  vesical  inflammation  known 
as  chronic  cystitis  may  travel  up  the  ureters  to  the  kidneys,  produc- 
ing ureteritis,  pyelitis,  pyonephrosis,  or  renal  abscess.  This  affec- 
tion seems  more  commonly  to  attack  the  left  ureter  and  kidney.  I 
say  seems,  that  being  simply  my  opinion,  derived  from  the  cases 
that  I  have  seen  or  of  which  I  have  read.  I  know  of  no  statistics 
upon  the  subject.  This  complication  is  not  so  common  in  females 
as  in  males,  which  is  owing,  perhaps,  to  the  fact  that  their  short  ure- 
thra, being,  as  a  rule,  free  from  stricture,  and  seldom  obstructed 
otherwise  for  any  length  of  time,  the  inflammation  of  the  bladder 


ORGANIC  DISEASES  OF  THE  BLADDER.  719 

has  less  tendency  to  extend,  is  less  severe,  and,  as  a  rule,  is  earlier 
and  more  easily  treated  locally  than  in  the  male. 

It  can  not  be  denied  that  the  damming  back  of  urine  into  the 
ureters  and  renal  pelves  is  a  factor  in  the  production  of  disease  in 
these  parts.  Suppose  tliat  an  inflamed  ureter  becomes  blocked  up 
from  any  cause  (a  mucous,  purulent,  or  blood  phig  ;  by  the  impaction 
of  a  small  calculus  from  the  kidney  ;  thickening  of  its  mucous  mem- 
brane; or  hypertrophy  of  the  bladder-walls),  the  urine  l)eliind  the 
point  of  obstruction  greatly  distends  the  ureter  and  renal  pehds,  de- 
composes, and  produces  acute  pyelitis,  which  often  leads  to  destruc- 
tion of  the  kidney  on  that  side. 

In  post-mortem  examinations  of  such  cases  it  will  be  found  that 
the  mucous  membrane  of  the  dilated  ureter  and  pelvis  of  the  kid- 
ney is  swollen,  pulpy,  and  of  a  dirty-drab,  grayish,  or  greenish  color, 
and  possibly  with  incrustations  of  saline  matter  upon  its  surface. 
The  renal  pelvis  may  be  sacculated,  and  the  pouches  may  contain 
shreds  of  membrane,  thickened,  dirty  pus,  and  saline  matter.  The 
kidney,  when  free  from  organic  lesion,  is  always  sympathetically 
affected,  being  enlarged  and  congested.  Abscesses  of  the  kidney 
itself  have  been  found  in  these  cases. 

The  inflamed  and  dilated  pelvis  of  the  kidney,  gradually  enlarg- 
ing, flattens  out,  and  implicates  the  papillae,  and  later  the  pyramids 
in  the  inflammatory  process,  until,  finally,  the  whole  organ  is  con- 
verted into  a  sacculated  abscess. 

When  there  is  destructive  inflammation  of  the  kidney  (tlie  ureter 
not  being  obstructed,  and  the  pus  having  a  free  exit),  the  organ 
shrinks  until  it  is  converted  into  a  little  shriveled  body,  weighing 
from  a  few  drachms  to  an  ounce  or  two.  If  the  purulent  matter  has 
not  free  exit,  it  fills  the  kidney,  and  becomes  thick  and  putty-like, 
cutting  like  fresh  cheese.  This  may  be  the  case  where  the  punilent 
matter  can  not  or  does  not  escape  from  the  kidney,  the  ureter  being 
perfectly  free  throughout.  The  septa  between  the  saccnli  are  occa- 
sionally calcified. 

The  pyi^amids  alone  may  suffer,  their  tissue  being  converted  into 
purulent  matter,  the  whole  having  the  appearance  of  soft  putty,  in 
some  cases  studded  with  calcareous  masses.  When  the  purulent 
matter  is  washed  out,  the  hole  left  looks  as  though  the  pyramid  had 
been  punched  out,  so  smooth  and  clean  cut  are  its  edges. 

Again,  the  kidneys  may  be  studded  with  miinite  al)scesses. 
Where  one  kidney  is  wholly  or  partially  destroyed,  the  other,  if 
healthy,  is,  as  a  rule,  largely  hypertrophied. 

In  some  cases  of  long  standing  the  affected  kidney  docs  not  break 


720  DISEASES   OF   WOMEN. 

down  into  purulent  matter,  but  by  a  slower  process,  probably  that 
of  chrouic  congestion,  becomes  granular  and  contracted. 

The  study  of  the  renal  complications  of  cystitis  is  a  very  interest 
ing  and  instructive  one,  but  it  is  too  extensive  to  permit  of  anything 
like  a  full  discussion  here.  For  a  more  elaborate  consideration  of 
the  subject,  I  must  refer  to  the  special  books  on  renal  diseases. 

Symjytomatologij. — The  various  forms  of  cystitis  being  simply 
stages  of  the  same  disease,  I  shall  speak  of  their  symptoms  all  nuder 
one  head. 

They  may,  for  convenience  sake,  be  divided  as  follows: 

1.  Symptoms  referable  to  the  organ  or  its  contents. 

2.  Symptoms  referable  to  neighboring  organs,  that  suffer  either 
from  sjnnpathy  or  through  direct  extension. 

3.  Spuptoms  referable  to  various  conditions  of  the  general  sys- 
tem, as :  {a)  The  vascular  system.  {!))  The  digestive  tract,  {c)  The 
cutaneous  surface,  {d)  The  nervous  system — cephaHc  and  sul)- 
cephalic. 

1.  The  symptoms  referable  to  the  organ  itself  are  chiefly  de- 
rangement of  function — viz.,  pain,  tenesmus,  and  frequent  urination. 
The  symptoms  vary  in  severity  according  to  the  extent  and  intensity 
of  the  cystitis.  In  the  mildest  form  of  the  trouble  there  is  frequent 
desire  to  pass  water,  which  often  comes  with  unusual  force.  Mic- 
turition is  followed  by  a  desire  to  strain,  called  vesical  tenesmus,  as 
if  the  organ  had  not  been  fully  emptied.  In  the  more  acute  cases 
this  gives  rise  to  the  most  intense  agony,  the  patient  remaining  on 
the  vessel  for  hours  at  a  time.  The  sensation  of  a  few  drops  of  urine 
i-emaining  in  the  bladder  may  pass  off  in  a  few  moments,  but,  as  a 
]'ule,  returns  after  each  micturition. 

As  the  disease  advances,  and  ulcerative  changes  take  place,  this 
vesical  tenesmus  returns  in  full  force,  and  the  powerful  squeezing 
together  of  the  bladder-avails  during  and  after  urination  produces 
intense  pain.  Sometimes  pains  shoot  up  into  the  breast  or  the  re- 
gion of  the  umbilicus.  There  is  often  a  dull,  heavy  aching  in  the 
perinaeum.  In  nearly  all  cases  there  is  continuous  backache,  or,  more 
correctly,  sacral  pain.  These  pains  seem  to  be  most  severe  in  cases 
of  long  standing,  where,  upon  an  already  ulcerated  surface,  an  acute 
inflammation  is  set  up  by  errors  in  diet,  medicines,  violence  in  cath- 
eterization, i-apid  changes  in  temperature,  and  the  weather. 

The  condition  of  the  urine  in  acute  or  chronic  cystitis  is  of  im- 
portance, but  if  reliance  is  placed  upon  it  alone  for  a  diagnosis  there 
will  be  many  disappointments.  The  specific  gravity  is  usually  low 
in  the  more  chronic  types,  varying  from  I'OOS  to  1-018,  being  usu- 


ORGANIC  DISEASES  OF  THE  BLADDER.  721 

ually  about  I^OIO.  In  the  primary  acute  form  the  gravity  is  little 
if  anything  below  the  normal,  and,  if  there  is  marked  fever,  may 
rise  as  high  as  1*030.  In  acute  attacks  engrafted  on  a  chronic  state, 
the  gravity  is  usually  low.  When  the  speciiic  gravity  is  low  in  acute 
cystitis,  if  not  dependent  on  the  diluent  drinks  and  diuretics  given, 
it  is  probably  due  to  a  slight  sympathetic  hypersemia  of  the  kidneys. 
The  low  gravity  in  chronic  cystitis  is  possibly  due  to  the  same  cause, 
and  a  urine  not  only  proportionally  but  really  deficient  in  the  urin- 
ary salts  is  excreted.  To  tliis  may  be  attributed  many  of  the  ursemic 
(ammonsemic)  symptoms  accompanying  the  disease,  which  are  sup- 
posed by  many  to  be  due  to  absorption  of  decomposed  urine.  That 
such  absorption  might  take  place  after  ulcerative  processes  had  be- 
gun, or  even  slight  epithelial  erosion  had  taken  place,  there  can  be 
no  doubt ;  but  it  is  a  question  whether  we  are  to  look  to  the  absorp- 
tion from  the  eroded  bladder  as  the  only  method  of  their  production. 
I  shall  speak  of  this  more  fully  very  soon. 

The  reaction  of  the  urine  in  acute  cases,  when  the  affection  is 
not  due  to,  or  accompanied  by,  retention,  is  at  first  usually  acid.  If 
there  be  retention,  the  reaction  is  usually  alkaline,  due  partly  to  the 
fixed  alkali  of  the  mucus  which  is  present  in  excess,  but  chiefly  to 
the  ammonia  disengaged  in  the  breaking  down  of  the  urea.  In 
chronic  cystitis  the  reaction  is  almost  invariably  alkaline,  being  in- 
tensely ammoniacal. 

In  the  primary  acute  form,  the  color  is  but  slightly  altered. 
The  presence  of  a  little  blood  may  give  to  the  urine  a  smoky  tint, 
and  if  decomposed  it  will  look  hazy  and  perhaps  contain  sparkling 
crystals  of  the  triple  phosphate.  In  the  chronic  form  the  nriue  is 
of  a  pale,  dirty  yellow  hue,  and  may  be  of  a  deep  red  from  the 
presence  of  considerable  blood. 

The  odor  is  ammoniacal  in  the  acute  type,  if  the  urine  be  de- 
composed, otherwise  it  is  normal.  In  the  chronic  form  it  has  not 
only  an  ammoniacal  but  a  peculiar  pungent  odor  of  flesh.  This  is 
usually  known  as  organic^  from  the  fact  that  it  is  due  to  the  amount 
of  organic  material  present. 

The  sediment  in  acute  cystitis  is  usually  mucus,  sometimes  pus 
(white  and  clinging  to  the  bottom,  or  somewhat  fiocculent).  It  may 
be  tinged  with  blood,  or  rendered  denser  and  whiter  from  the  pres- 
ence of  the  amorphous  and  triple  phosphates.  In  chronic  cystitis 
the  sediment  is  commonly  heavy,  and  of  a  dirty  brown  or  brownish 
yellow  color.  Flakes  of  pus,  shreds  of  tissue,  as  well  as  blood  and 
epithelial  elements,  cause  it  to  vary  greatly  in  different  cases. 
When  the  intense  alkalinity  of  the  urine  has  rendered  the  pus  gelat- 

47 


722  DISEASES  OF  WOMEN. 

inous,  the  sediment  is  seen  as  a  ropy  mass  that  clings  tenaciously 
to  the  bottom  of  the  vessel  when  inverted,  or  slides  about  in  a  jelly- 
hke  mass. 

Microscopically,  this  sediment  presents  a  varied  and  interesting 
appearance.  In  the  acute  form  numerous  HbrillaB  of  mucus,  a  few 
pns-corpuscles,  and  possibly  blood-globules  are  to  be  seen,  and  if  de- 
composition has  taken  place,  the  amorphous  and  trij)le  j)hosphates. 

In  chronic  cystitis  pus-corpuscles  are  usually  present  in  large 
amount.  There  is  also  a  varying  amount  of  mucus,  triple  and  amor- 
phous phosphates,  spheres  of  the  urate  of  ammonia,  organic  delris^ 
and  in  some  cases  epithelial  elements.  In  the  advanced  stages  of 
chronic  cystitis  epithelial  elements  of  any  kind  are  very  rarely  found. 
It  is  only  in  the  earlier  stages  that  normal  and  transitional  forms  of 
vesical  epithelium  are  present.  Even  then  dependence  must  not  be 
placed  upon  that  alone  in  making  a  differential  diagnosis,  lest  a  pye- 
litis may  be  mistaken  for  a  cystitis,  or  vice  versa  ;  the  transitional 
forms  of  epithelium  from  the  bladder  closely  resembling  the  nor- 
mal epithelium  from  certain  other  parts  of  the  urinary  tract.  The 
return  to  a  healthy  condition  is  marked  by  the  disappearance  of  pus  ; 
the  reappearance  of  epithelium  in  the  urine,  first  transitional,  then 
perfect ;  while  the  products  of  inflammation  decrease  in  amount  and 
finally  disappear  altogether.  When  there  is  sympathetic  congestion 
of  the  kidneys,  small  light  granular  and  hyaline  casts  may  be  found. 
If  organic  renal  disease  is  present,  large,  small,  and  medium-sized 
hyaline,  light  and  dai'k  granular,  and  pus  casts  will  be  found,  as 
also  epithelial  and  blood  casts.  In  some  cases,  where  extensive  de- 
structive change  has  taken  place  in  the  kidneys,  no  evidences  are 
found  in  the  urine,  either  during  its  progress  or  after  its  completion. 

Upon  testing  the  urine  chemically,  albumen  will  be  found  in 
proportion  to  the  amount  of  pus  oi-  blood  present.  If  renal  disease  co- 
exist, the  amount  of  albumen  will  be  greatly  increased.  In  chronic 
cystitis  without  renal  disease  the  amount  of  albumen  in  a  number 
of  cases  studied  varied  from  one  sixteenth  to  one  fifth  of  the  bulk 
of  urine.  There  is  usually  a  real  excess  of  both  fixed  and  volatile 
alkaline  salts,  as  also  of  the  earthy  and  alkaline  phosphates  and  the 
chloride  of  sodium. 

In  the  advanced  stages,  where  there  is  a  depraved  condition  of 
the  blood,  urohaematin  is  present  in  a  marked  degree,  and  urea  is 
either  somewhat  or  decidedly  diminished.  In  other  cases,  and  at 
first,  the  urea  may  be  present  in  normal  amount. 

2.  Symptoms  Referable  to  Neighboring  Organs. — These  are  not 
especially  marked.     In  some  cases,  with  the  intense  vesical  tenes- 


ORGANIC  DISEASES  OF  THE  BLADDER.  723 

raus,  there  may  exist  an  irritable  condition  of  tlie  rectum,  with  some 
tenesmus  and  pain  at  stool. 

The  uterus  is  often  congested,  which  causes  a  free  leucorrhoea ; 
subinvolution  often  occurs  after  the  confinement  of  those  who  have 
had  cystitis  during  pregnancy.  Extension  of  the  inflammation  in 
extreme  cases  may  cause  metritis  and  pelvic  cellulitis  and  perito- 
nitis. The  symptoms  thus  arising  will  be  characteristic  of  the  dis- 
ease of  the  organs  or  tissues  involved. 

Menstruation  may  be  \ariously  disturbed ;  menorrhagia,  metror- 
rhagia, or  amenorrhea  resulting  either  from  congestion,  inflamma- 
tory extension,  or  reflex  nervous  influence. 

Neuralgia  of  the  uterus  or  ovaries  may  also  be  produced  in  this 
way.  I  have  just  said  that  subinvolution  of  the  uterus  is  almost 
sure  to  follow  a  pregnancy  occurring  during  the  existence  of  a 
chronic  vesical  inflammation,  and  I  am  inclined  to  believe  that  the 
same  result  is  produced  in  some  cases  by  an  acute  cystitis  following 
delivery. 

Renal  disturbances  upon  which  I  have  already  touched  will  be 
spoken  of  more  at  length  hereafter. 

3.  Symptoms  Referable  to  Disturbances  of  the  General  System. — 
These  symptoms  may  be  due  to  reflex  nervous  influence,  or  to  di- 
rect blood-poisoning.     For  convenience  sake  I  will  first  consider : 

(«)  The  Vascular  System. — Although  there  has  been  much  dis- 
pute among  authors  as  to  how  and  by  what  the  general  poisoning  is 
caused,  there  seems  to  be  no  question  as  to  whether  such  a  poison- 
ing really  does  take  place.  As  general  systemic  effects  may  be  pro- 
duced by  two  separate  blood  conditions,  I  will  discuss  the  subject 
under  two  heads,  prefacing  their  consideration,  however,  with  the 
remark  that,  as  a  rule,  the  two  conditions  exist  together.  They  are  : 
first,  abnormal  ingredients  existing  in  the  blood ;  and,  second,  a  poor 
condition  of  the  blood  itself  (antemia). 

The  poisoning  of  the  general  system  that  usually  complicates 
cystitis  of  long  standing  may  be  produced  in  three  ways,  viz : 

1.  Organic  renal  disease,  or  renal  hyperaemia  (sympathetic), 
leading  to  imperfect  elimination  of  urinary  salts. 

2.  Direct  absorption  of  one  or  more  of  the  ingredients  of  the 
decomposed  urine  (ammonaemia,  urinsemia). 

3.  Absorption  of  purulent  or  septic  matter,  produced  by  decom- 
position of  sloughing  tissue  and  organic  debris. 

1.  Probably  in  almost  all  cases  of  chronic  cystitis  the  kidneys 
are  kept  in  a  more  or  less  active  or  passive  liyperaMuic  state ;  and 
while  eliminating  a  normal  amount  of  fluid,  fail  to  rid  the  blood  of 


724:  DISEASES   OF   WOMEN. 

the  acciimu  latin  or  salts ;  and  thereby  a  slow,  steady  blood  and  tissue 
poisoning  is  brought  about.  So  slow  is  it,  that  the  system  seems  to 
establish  a  certain  amount  of  tolerance  for  the  poison. 

A  French  experimenter  has  fouud  that  a  small  amount  of  urea 
is  daily  eliminated  by  the  mucous  membrane  of  the  bowels  in 
health,  and  we  know  that  in  renal  diseases,  with  partial  or  total  sup- 
pression of  urine,  the  bowels  are  largely  concerned  in  the  elimina- 
tion of  the  poison  from  the  system.  In  this  manner  may  be  ex- 
plained the  occasional  attacks  of  vomiting  and  almost  uncontrollable 
diarrhcea  in  bad  cases  of  cystitis.  Of  course,  when  destructive  renal 
disease  com})licates  the  cystitis,  the  general  poisoning  is  more 
marked  and  more  readily  explained. 

2.  In  the  chapter  on  the  function  of  tlie  bladder  I  pointed  out 
that  experimenters  had  pretty  well  established  the  fact  that  a  nor- 
mal vesical  mucous  membrane  was  unable  to  absorb  anything  except 
possibly  a  little  water,  but  that  where  erosion  of  the  epithelial  surface 
or  ulceration  existed,  absorption  was  possible.  This  being  the  case, 
it  will  at  once  be  seen  how  easy  it  is  for  a  patient  suffering  with 
chronic  cystitis  to  become  poisoned  by  the  absorption  of  decomposed, 
ammoniacal  urine  in  the  bladder.  Whether  the  materies  morbi 
be  the  urea,  the  ammonia,  or  all  or  part  of  the  urine,  is  not  as  yet 
definitely  settled.  This  form  of  poisoning  by  absorption  has  been 
denied  on  the  ground  that  the  urine  remains  but  a  short  time  in 
the  bladder  owing  to  the  intense  vesical  tenesmus,  and  that  the 
eroded  surface  is  faii'ly  well  shielded  from  contact  with  the  urine  by 
mucus  or  gelatinous  pus,  and  that  therefore  there  is  neither  time  nor 
opportunity  for  absorption.  As  against  these  arguments,  let  me  say 
that  of  all  kinds  of  urine,  the  highly  limj^id  seems  the  most  easily 
absorbed ;  that  poisoning  is  not  supposed  to  be  due  to  the  fresh 
urine  that  comes  directly  from  the  kidneys,  but  to  its  decomposing 
sediment,  caught  in  the  meshes  of  the  mucus  and  muco-pus.  Fur- 
ther, the  intense  vesical  tenesmus,  while  keeping  the  bladder  com- 
paratively empty,  thoroughly  mixes  the  decomposing  unne  with 
the  mucus,  thus  at  each  micturition  applying  freshly  charged  de- 
composing matter  to  the  eroded  and  ulcerated  surface.  It  will  also 
be  observed  that  in  some  cases  where,  by  the  use  of  oj^iates  or  in  the 
course  of  the  disease  itself,  the  tenesmus  wholly  or  in  part  al)ates 
and  the  urine  remains  in  the  bladder  for  a  longer  period  than  usual, 
the  patient,  while  feeling  greatly  relieved  by  not  having  the  inces- 
sant calls  to  urinate,  still  begins  to  experience  a  peculiar  sensation 
of  sleejnness  and  the  other  manifestations  of  systemic  poisoning. 
That  this  is  not  due  to  the  opiates  or  other  remedies  used,  is  evident 


OKGANIC  DISEASES  OF  THE   BLADDER.  725 

from  the  fact  that  as  large  or  larger  closes  of  the  same  remedies  do 
not  produce  these  peculiar  results  when  given  at  times  when  the 
vesical  tenesmus  is  marked.  It  is  undoul)tedly  explained  by  the 
fact  that  the  bladder  has  more  time  to  absorb  a  part  of  its  contents, 
which,  when  absorbed,  produce  these  results. 

3.  Blood  contamination  due  to  the  absorption  of  purulent  or  sep- 
tic matter. — This  material  may  be  the  liquor  intris^  the  disinte- 
grated corpuscles  of  pus,  or  possibly  the  whole  corpuscles,  as  also  the 
decomposed  shreds  of  sloughed  membrane  and  organic  debris. 

I  think  there  is  little  doubt  but  that  such  material  is  at  times  ab- 
sorbed, and  gives  rise  to  the  peculiar  septiesemic  or  pyaemic  symp- 
toms. The  chill,  fever,  and  sweating,  with  peculiar  head  symptoms 
(all  to  be  spoken  of  more  fully  hereafter),  the  sudden  diarrhoea,  with 
copious  black,  offensive  liquid  stools,  are  probably  caused  in  this  way. 

Whether  the  general  symptoms  are  produced  at  the  time  of  each 
absoj'ption,  or  whether  by  slow  degrees  the  poisonous  material  col- 
lects, and,  tolerance  being  finally  exhausted,  nervous  disorder,  with 
a  powerful  effort  at  excretion  by  the  bowels,  results,  we  do  not 
know. 

4.  Depraved  blood  condition  —  (anaemia). — In  cystitis  of  long 
standing,  owing  to  frequent  haemorrhages,  poor  digestion,  excessive 
diaphoresis  and  diuresis,  and  reflex  nervous  influences,  the  blood  be- 
comes poor  in  red  corpuscles  and  fibrin.  Injuries  on  persons 
thus  affected  do  not  heal  readily,  and  poor  tissue  renovation  is  a 
general  accompaniment  of  this  affection.  Cerebral  anaemia  is  an 
accompanying  complication,  due  to  the  same  cause,  and  various  ab- 
normal nervous  phenomena  result  from  poor  nourishment  of  nerve- 
tissue.  All  the  fluids  and  solids  of  the  body  are  but  poorly  con- 
structed, and  imperfect  performance  of  function  necessarily  results. 
This  i30or  blood  condition,  as  I  have  already  said,  is  manifested  by 
the  presence  of  urohaematin  in  the  urine. 

(J)  The  Digestive  Tract — Anorexia,  especially  at  the  morning 
meal,  is  a  common  accompaniment  of  chronic  cystitis.  In  some  cases 
this  is  the  only  meal  where  the  appetite  does  not  invite  the  patient 
to  partake.  A  longing  for  peculiar  foods  is  also  very  common,  the 
patient  often  having  lost  the  desire  before  the  article  in  question 
reaches  her.  The  common  symptoms  of  disordered  digestion  ai'e 
usually  present,  and  the  affection  may  be  either  of  the  nervous  type, 
or  of  the  chronic  catarrhal  form ;  it  is  usually  a  mixture  of  both. 
If,  as  is  believed,  the  poisonous  material  absorbed  from  the  bladder 
and  the  non-eliminated  urinary  salts  find  vent  through  the  aliment- 
ary canal,  we  have  no  trouble  in  discovering  a  cause  for  the  catar- 


72G  DISEASES  OF   WOMEN. 

rlial  disorder.  The  uervous  disorders  are  readily  explained  by  tlio 
effects  of  the  abuoriiial  condition  of  the  blood,  and  the  broken  and 
sleejjless  nights  which  interrupt  and  retard  the  nutrition  of  the 
nervous  system. 

The  bowels  are  usually  irregular  and  constipated,  and  require 
daily  enemata  to  open  them.  This  costiveness  is  occasionally  in- 
terrupted by  a  profuse  watery  diarrhoea,  which  would  seem  to  be 
an  effort  of  nature  to  relieve  the  blood  of  its  abnormal  contents,  as 
I  have  already  said.  It  may  last  for  days  or  for  only  a  few  houre, 
and  the  discharges  are  usually  rich  iu  the  carbonate  of  ammonia. 
The  septicemic  diarrhoea  differs  usually  in  the  great  prostration  ac- 
companying it,  the  chai'acter  of  the  stools  (black  or  greenish  black, 
and  very  offensive,  the  organic  odor  quite  or  partly  hiding  the 
ammoniacal  odor),  and  the  fact  that  it  is  usually  preceded  or  accom- 
panied by  chills,  fever,  and  sweating.  If  checked  too  abruptly, 
head  symptoms,  mild  muttering  delirium,  etc.,  are  likely  to  follow. 

The  results  of  imperfect  digestion  are  seen  in  the  poor,  un- 
healthy condition  of  the  patient's  flesh  and  skin,  and  all  the  signs  of 
malnutrition  present. 

((?)  The  Cutaneous  Surface. — The  skin  of  patients  with  chronic 
cystitis  is  usually  sallow,  loose,  and  has  a  lifeless  feel.  Indeed,  one 
might  almost  make  a  diagnosis  from  the  comjjlexion  alone.  Sweat- 
ing of  the  palms  of  the  hands  and  soles  of  the  feet  is  common.  In 
low  states  of  the  system  the  patients  are  especially  liable  to  night- 
sweats.  The  perspiration  sometimes  has  a  urinous  odor.  I  have  al- 
ready spoken  of  the  septicaemic  diaphoresis. 

{d)  The  Nervous  System. — I  will  first  consider  the  symptoms 
appertaining  to  the  brain  and  its  function,  and  then  to  the  sub- 
cephalic  nervous  system. 

There  is  a  peculiar  brain  condition,  supposed  by  some  to  be 
caused  by  cerebral  annemia  ;  others  attribute  it  to  a  peculiar  poison 
circulating  in  the  blood.  By  anaemia  of  the  brain  in  this  connec- 
tion is  meant  not  only  lack  of  blood  in  that  organ,  but  an  exceed- 
ingly impoverished  condition  of  the  blood  there  circulating.  Those 
remedies  that  tend  to  lessen  the  amount  of  blood  in  the  brain,  as 
bromide  of  potassium  and  ergot,  produce  most  unpleasant  symp- 
toms in  these  cases,  such  as  dizziness  and  fainting.  Medicines 
which  act  in  a  manner  to  congest  the  brain,  if  given  in  small  doses, 
improve  this  condition,  as  also  do  the  ferruginous  tonics,  especially 
iron  by  hydrogen.  From  this  it  would  appear  that  this  pecuUar  con- 
dition is  due  more  to  the  amount  and  imperfect  constitution  of  the 
blood  circulating  in  the  brain,  than  to  the  absorbed  or  non-eliminated 


ORGANIC  DISEASES   OF   THE   BLADDER.  727 

urinary  matter.  Against  this  theory,  however,  is  the  fact  that  when 
the  vesical  tenesmus  is  least  and  the  urine  remains  in  the  bladder 
longest,  and  hence  the  blood-poisoning  is  presumably  the  greatest, 
the  weak  and  somnolent  feeling  is  the  worst.  Both  causes  probably 
act  to  produce  this  condition.  By  some,  however,  this  cerebral 
aufemia  is  attributed  partly  to  the  poor  blood  condition,  but  chiefly 
to  imperfect  circulation  due  to  want  of  exercise.  This  view  is 
supported  by  the  fact  that  digitalis  and  exercise  in  the  open  air 
greatly  improve  these  patients. 

When  septic  complications  arise  and  the  patient  becomes  very 
low,  or  when  the  septic  diarrhoea  is  checked  too  suddenly,  low,  mut- 
tering delirium  with  hallucinations  commonly  results.  This  has 
been  alluded  to  before.  The  mind  is  usually  markedly  affected, 
the  patients  feeling  "  blue,"  morose,  lacking  hope,  confidence,  and 
spirit.  At  times,  indeed,  they  become  so  despondent  as  to  seriously 
contemplate  suicide.  The  little  rest  that  they  get  at  night  is  often 
broken  by  horrible  dreams  and  nightmare.  I  am  now  speaking  of 
the  most  severe  cases. 

The  subcephalic  nervous  system  is  seldom  affected  beyond  oc- 
casional irregular  action  of  the  heart,  chills,  fever  and  sweating, 
and  occasional  neuralgia.  Pains  in  the  nipple,  abdomen,  arms,  legs, 
hands,  and  feet,  are  by  no  means  rare.  The  vesical  pain  has  already 
been  referred  to.  Of  course  all  these  symptoms  that  I  have  spoken 
of  as  accompanying  cystitis,  do  not  occur  in  each  case,  nor  are  the 
greater  part  of  them  peculiar  to  cystitis  alone.  I  now  pass  to  diag- 
nosis. 

Diagnosis. — The  diagnosis  of  cystitis  is  generally  easy  in 
marked  cases,  but  in  mild  attacks  care  is  necessary  to  distinguish  it 
from  other  conditions  that  cause  similar  symptoms. 

Frequent  urination  occurs  in  many  other  troubles,  such  as  pro- 
lapsus uteri,  adhesions  from  pelvic  peritonitis,  with  abdominal  tu- 
mors, and  in  various  neuroses.  Pregnancy,  also,  sometimes  gives  rise 
to  annoying  frequency  of  micturition.  Frequent  urination  from 
prolapsus  is  worse  when  the  patient  is  standing  or  walking,  and  is 
relieved  wholly,  or  to  a  great  extent,  by  the  recumbent  position ; 
while  in  cystitis,  position  makes  no  marked  difference. 

I  have  seen  one  very  interesting  exception  to  this  general  rule. 
The  patient  had  a  complete  prolapsus  for  many  years,  and  when  in 
the  erect  position  she  could  retain  the  urine  for  an  ordinary  length  of 
time,  but  when  she  was  reclining  the  most  urgent  desire  to  urinate 
came  on,  and  she  could  only  retain  a  very  small  quantity  of  urine. 
The  cause  of  this  I  found  to  be  iniiannnation  of  the  neck  of  the 


728  DISEASES   OF    WOMEN. 

bladder.  When  in  the  upright  position  tlio  urine  settled  down  in 
the  dependent  portion,  but  while  recumbent  the  pressure  came  on 
the  tender  part. 

In  adhesions  from  pelvic  peritonitis,  abdominal  tumors,  and 
pregnancy,  the  desire  to  urinate  only  comes  on  wdien  the  bladder  is 
partly  tilled,  and  is  about  the  same  day  and  night.  Frequency  of 
urination  is  not  usually  accompanied  by  tenesmus,  except  when  due 
to  cystitis.  In  the  various  forms  of  vesical  neuroses  frequent  urina- 
tion is  very  irregular,  the  patient  at  times  being  almost  entirely  free 
from  it,  and  at  other  times  very  much  troubled. 

The  frequent  and  painful  urination  of  cystitis  may  be  simulated 
by  urethritis  and  other  painful,  irritable  conditions  of  the  uretlira. 
The  distinction  can  be  made  usually,  from  the  fact  that  in  urethral 
disease  there  is  no  vesical  tenesmus,  or  if  any,  it  is  much  less  than 
in  cystitis.  There  are  acute  pain  in  the  act  of  urination,  and  a  burn- 
ing sensation  in  the  urethra,  wdiich  sometimes  cause  sympathetic 
vesical  tenesmus ;  but  when  this  latter  passes  off  the  bladder  will 
tolerate  distention  to  the  fullest  extent. 

The  urine  should  be  carefully  examined  and  the  results  as  care- 
fully considered.  Implicit  dependence,  however,  must  not  be 
placed  on  the  condition  of  the  urine.  Acute  or  chronic  congestion 
may  produce  considerable  mucus  that  is  sometimes  mistaken  for  pus 
that  has  become  gelatinous  by  the  action  of  strong  alkali.  Pus  may 
be  present  in  the  urine  from  suppuration  of  the  upper  urinary  pas- 
sages (pyonephrosis,  renal  abscess,  and  pyelitis)  ;  from  abscesses  of 
neighboring  organs  or  tissues  opening  into  the  bladder,  as  in  colitis 
and  pelvic  cellulitis.  When  there  is  doubt  on  this  point,  Sir  Henry 
Thompson's  method  of  procedure  as  recommended  l)y  Van  Buren 
and  Keyes  for  detecting  the  source  of  blood  should  be  tried. 

A  differential  diagnosis  between  cystitis  and  pyelitis,  by  means 
of  the  urine  alone,  is  almost  an  impossibility,  especially  in  the 
later  stages  of  the  former.  Thompson's  method,  the  endoscope, 
and  the  presence  or  absence  of  a  tumor  in  the  loins,  with  the  gen- 
eral sjnnptonLS,  must  be  the  guides.  Xo  dependence  can  be  ))laced 
on  the  epithelium,  as  transitional  forms  from  the  bladder,  as  already 
explained,  are  very  likely  to  be  mistaken  for  the  normal  epithelium 
of  the  renal  pelves,  and  lead  to  error. 

To  make  a  positive  and  reliable  diagnosis,  resort  must  be  had  to 
physical  exploration  of  the  organ.  The  methods  of  exploration  are 
palpation,  percussion,  and  auscultation  of  the  abdomen  ;  examination 
of  all  the  pelvic  organs  by  the  touch  and  speculum  ;  and  lastly,  ex- 
ploration of  the  bladder  by  the  catheter,  or  sound. 


ORGANIC  DISEASES   OF  THE  BLADDER.  729 

By  palpation  and  percussion  of  the  abdomen  tenderness  and  dis- 
tention of  the  bladder  may  be  detected,  if  either  exists.  By  the 
same  means  it  may  be  ascertained  whether  the  bladder  is  contracted 
and  its  walls  thickened,  rigid,  or  relaxed. 

Auscultation  will  possibly  reveal  friction  sounds  in  cases  where 
inflannnation  has  extended  to  the  serous  coat,  and  caused  roughen- 
ing by  exudation  on  the  peritoneal  surfaces.  These  may  seem  to 
be  rather  delicate  points  in  examination,  but  in  obscure  cases  we 
must  avail  om'selves  of  all  the  means  that  can  give  the  slightest  evi- 
dence. 

Examination  of  the  pelvic  organs  by  touch  will  detect  any  disease 
of  these  organs  that  may  either  cause  or  complicate  the  cystitis. 
Displacements  and  inflammatory  ailections  of  the  uterus,  vagina,  or 
rectum,  pelvic  peritonitis,  or  the  products  of  a  former  attack  of  that 
disease,  ovarian  diseases  and  tumors,  should  be  carefully  sought  for, 
and — if  present — their  relations  to  the  vesical  trouble  carefully 
studied. 

Cystitis  produced  by  or  producing  pelvic  cellulitis  and  peritonitis 
has  the  same  symptoms  as  ordinary  purulent  vesical  inflammation, 
plus  those  of  well-defined  pelvic  inflammation.  There  are  usually 
pain  and  tenderness  of  the  pelvic  organs,  and  the  symj)tomatic  fever 
of  local  inflammation. 

In  those  cases  where,  from  gluing  together  of  the  pelvic  organs, 
the  bladder-walls  are  separated  and  kept  upon  the  stretch,  inconti- 
nence often  results,  sometimes  overdistention  with  dribbling.  In 
such  cases  the  cystitis  may  be  entirely  secondary  to  the  pelvic  ad- 
hesions, and  consequent  vesical  distention.  The  urethra  should  be 
examined  with  care,  for  some  of  its  diseases  present  a  natural  history 
closely  resembling  that  of  some  vesical  affections. 

By  a  careful  use  of  the  catheter  or  sound  introduced  into  the 
bladder,  the  degree  of  tenderness  of  that  organ  can  be  determined, 
and  the  presence  of  foreign  bodies,  such  as  a  stone  in  the  bladder, 
can  be  excluded.  The  sound  being  in  the  l)ladder,  the  finger  may 
be  introduced  into  the  vagina,  and  the  posterior  and  inferior  walls 
be  examined  as  to  their  thickness  and  tenderness. 

In  supposed  cystitis  the  neck  of  the  bladder  ought  always  to  be 
examined  with  a  view  of  detecting  ulceration  and  fissures  at  that 
point.  These  fissures  give  rise  to  symptoms  very  closely  simulating 
cystitis,  and  the  differential  diagnosis  can  only  be  made  by  tlie  en- 
doscope. 

The  endoscope  affords  the  only  means  of  ascertaining  the  exact 
appearance  of  the  interior  of  the  bladder.    The  extent  of  congestion, 


730  DISEASES  OF  WOMEN. 

the  degree  and  extent  of  ulceration,  and  other  lesions  can  be  observed 
in  this  way,  and  this  instrument  should  be  used  in  all  cases  where 
the  diagnosis  is  doubtful,  or  when  the  case  does  notyelid  to  supj)06ed 
proper  treatment.  The  chief  value  of  the  endoscope  is  in  examining 
the  urethra  and  neck  of  the  bladder.  When,  by  the  use  of  this  in- 
stnimenfc,  urethral  disease  can  be  excluded,  the  diagnosis  of  cystitis 
may  be  made  by  exclusion.  If  this  is  not  satisfactory,  then  the 
bladder  should  be  emptied,  washed,  and  thoroughly  cleaned  of  all 
inflammatory  products.  The  catheter  should  be  left  to  drain  oif  the 
urine  as  fast  as  it  flows  into  the  bladder.  This  urine,  coming  almost 
directly  from  the  kidneys,  will  show  if  any  renal  disease  exists. 
Sometimes  the  bladder  is  too  irritated  to  permit  the  presence  of 
the  catheter ;  then  the  patient  should  urinate  as  soon  as  there  are  a 
few  drachms  secreted,  and,  if  there  should  be  any  evidence  of  renal 
disease,  the  diagnosis  would  be  complete. 

When  from  an  examination  of  the  urine  or  the  symptoms  it  is 
impossible  to  tell  whether  disease  of  the  kidneys  complicates  the 
vesical  trouble,  recourse  may  be  had  to  the  ophthalmoscope,  by  means 
of  which  renal  disease,  retinitis  albuminurica,  may  often  be  diagnosti- 
cated. 

Causation. — The  cause  of  acute  cystitis  may  for  convenience  be 
classed  under  five  heads,  each  of  which  will  be  studied  separately : 

1.  Direct  injuries,  such  as  blows  in  the  vesical  region,  falls,  fract- 
ures of  the  pelvic  bones,  violent  copulation,  sudden  uterine  displace- 
ments and  pressure  therefrom,  contusions  and  injuries  during  labor, 
foreign  bodies,  rough  catheterization,  and  overdistention  from  reten- 
tion of  urine. 

2.  Abnormal  urine. 

3.  Inflammation  of  adjacent  organs. 

4.  Constitutional  diseases. 

5.  Drugs,  improper  food,  and  the  virus  of  gonorrhoea. 

These  causes  also  pertain  to  chronic  cystitis,  whether  it  begins  as 
an  acute  or  subacute  alfection. 

1.  Direct  Injuries. — Blow^s  over  the  vesical  region,  falls,  and  espe- 
cially fracture  of  the  pelvic  bones,  caused  by  some  great  force,  usu- 
ally produce  acute  inflammation  of  the  bladder,  with  or  without 
rupture  of  that  organ.  The  bladder,  when  full,  is,  of  course,  more 
readily  ruptured  than  when  empty,  rupture  in  the  latter  condition 
being  almost  an  impossibility.  This  item  of  knowledge  can  be  turned 
to  practical  use  in  traveling,  either  by  rail  or  \^  ater,  by  remeuibering 
to  frequently  empty  the  bladder.  In  cystitis  from  severe  and  direct 
injury,  even  without  any  perceptible  traumatic  lesion  of  the  mucous 


ORGANIC  DISEASES   OF  THE  BLADDER.  731 

membrane,  there  is  apt  to  be  marked  Ini'morrhage,  irmch  greater, 
indeed,  than  in  cystitis  from  other  causes. 

Sudden  displacement  of  other  pelvic  organs,  as  the  uterus,  may 
act  in  two  ways:  First,  by  pressure  on  the  bladder,  or  by  dragging 
it  out  of  place  ;  second,  by  blocking  the  urethra  by  pressure.  These 
displacements  may  be  due  to  falls  or  blows,  and  it  is  not  an  uncom- 
mon occurrence  for  the  gravid  uterus  to  topple  over  by  its  own 
weight.  Supposing  a  retroversion  of  the  gravid  utenis,  the  cervix 
Av'ould  compress  the  urethra  against  the  pubes,  while  the  utero- vesi- 
cal ligament  would  drag  the  upper  part  of  the  bladder  downward 
and  backward.  Even  after  the  uterus  has  been  replaced,  and  the 
pressure  on  the  urethra  removed,  with  relief  of  the  vesical  overdis- 
tention,  the  retention  is  likely  to  persist,  and  overdistention  recur, 
for  b}'  the  pressure  the  urethra  becomes  much  tumelied,  and  the 
muscular  and  elastic  tissue  of  the  vesical  walls  overstretched  and 
partly  paralyzed.  If  the  distention  has  been  great  and  prolonged, 
there  may  be  partial  or  total  sloughing  of  the  vesical  mucous  mem- 
brane. 

In  retention  of  urine,  and  consequent  overdistention  of  the  blad- 
der during  or  after  labor,  from  either  injury  or  carelessness,  acnte 
cystitis  is  very  apt  to  occur.  Here  injury  of  a  serious  nature  may 
be  done  to  the  urethra  by  pressure  against  the  pubic  bones  by  the 
child's  bead,  with  or  without  the  intervening  soft  cushion  of  tlie 
anterior  nterine  lip.  This  is  especially  the  case  in  slow,  tedious 
labors,  where  the  pressure  is  almost  continuous. 

The  extent  to  which  the  bladder  may  be  distended  without  rupt- 
uring is  quite  wonderful.  My  friend  Dr.  Bodkin  invited  me  to  see 
a  lady  with  him  in  consultation,  who  went  without  urination  for  four 
days  and  nights  after  her  confinement.  The  bladder  reached  above 
the  umbilicus,  and  contained  about  three  or^iii^vy  joots-de-chamhre 
full  of  decomposed  urine,  which  was  drawn  off  by  the  catheter.  The 
bladder  remained  paralyzed  for  three  months  afterward,  but  finally 
regained  its  expelling  power.  At  the  time  I  saw  ber  she  was  suf- 
fering from  cystitis,  brought  on  by  the  maltreatment.  In  justice  to 
the  medical  profession,  I  ought  to  say  that  this  lady  was  attended 
in  her  confinement  and  for  a  time  after  by  a  member  of  the  so-called 
7iey)  school  of  medicine. 

The  ignorant  or  careless  use  of  instruments  during  delivery  is 
also  a  cause  of  serious  vesical  inflammation.  In  all  these  cases  the 
catheter  should  be  used  several  times  daily,  and  with  great  care, 
until  the  organ  has  regained  its  power,  and  the  contused  urethra 
fully  recovered  itself.     I  may  digress  here  long  enough  to  say  that 


732  DISEASES  OF  WOMEN. 

the  soft-rubber  catlieter  is  the  only  one  that  1  liave  used  for  years. 
The  old  female  silver  catheter  is  the  most  dangerous  instrument  I 
have  ever  seen.  It  should  be  discarded  forever.  In  cases  where 
the  bladder  has  been  perfectly  healthy,  and  the  catheter  pa.ssed  a 
number  of  times  by  way  of  experiment,  the  points  of  membrane 
with  wliich  the  instrument  had  come  in  contact  were  abraded  and 
congested,  thus  showing  the  danger  attending  the  unskillful  use  of 
this  instrnment.  If  the  frequent  introduction  of  the  instrument  into 
a  healthy  bladtler  produces  these  results,  how  easily  must  the  blad- 
der of  a  pregnant  woman  be  iutiamed  under  such  treatment,  for  the 
organ  has  been  for  a  time  more  or  less  congested,  and  during  labor 
perhaps  severely  bruised ! 

The  question  has  been  raised  as  to  w^hether  the  irritation  and  in- 
flammation following  catheterization  in  some  cases  is  not  due  to  the 
introduction  (during  manipulation)  of  air,  either  pure  or  containing 
germs  that  will  cause  decomposition  of  the  urine.  The  experiments 
of  P.  Dubelt,  in  which  the  air  was  injected  into  the  bladder,  show 
that  it  is  perfectly  harmless.  Moreover,  the  same  experimenter 
found  that  the  injection  of  decomposing  urine  into  the  bladder  did 
little  or  no  harm,  unless  the  mucous  surface  was  abraded.  What- 
ever may  be  the  effect  of  such  things  on  a  healthy  bladder,  I  do  not 
doubt  but  tliat  the  introduction  of  germs  by  means  of  air  or  a  dirty 
catheter,  decomposing  urine,  or  the  rough  or  too  frequent  use  of  a 
catheter,  would  produce  an  acute  exacerbation  in  an  organ  already 
diseased. 

The  influence  of  decomposed  or  decomposing  urine  in  producing 
inflammation  of  the  bladder  will  be  more  fully  spoken  of  again. 

Forcible  and  excessive  copulation  is  a  decided  exciting,  as  well 
as  predisposing,  cause  of  acute  or  subacute  cystitis,  and,  if  persisted 
in,  a  chronic  inflammation  of  the  bladder  is  usually  the  result. 

Foreign  bodies  in  the  bladder,  such  as  pieces  of  wood,  pins, 
needles,  hair-pins,  bodkins,  'and  the  like,  that  are  sometimes  slipjied 
in  by  hysterical  girls  and  those  w^ho  masturbate,  excite  acute  inflam- 
mation if  not  speedily  removed. 

2.  Abnormal  Urine. — No  known  abnormality  of  the  urine  will,  I 
think,  excite  acute  inflammation  in  a  perfectly  healthy  bladder.  In 
a  bladder,  however,  that  is  suffering  from  chronic  congestion ;  in 
one  whose  walls  bear  deposits  of  tubercle ;  in  cases  where  some 
slight  degree  of  inflammation  already  exists,  then  abnormal  urine 
may  and  does  give  rise  to  marked  inflammatory  trouble.  As  a  rule, 
however,  inflammatory  vesical  disease  precedes  urine  decomposition. 
In  cystitis  following  overdistention,  the  retained  urine,  being  mixed 


ORGANIC   DISEASES   OF   THE   BLADDER.  .     733 

with  mucus  thrown  out  by  the  irritated  and  tense  mucous  membrane 
to  shiekl  itself,  rapidly  decomposes,  and  still  further  aggravates  the 
abnormal  condition  of  the  membrane. 

Women  sometimes  from  abnormal  modesty,  more  often  from 
the  lack  of  opportunity,  retain  their  urine  until  the  bladder  is  dis- 
tressingly overdistended,  and  the  urine  partially  decomposed.  Of 
course  this  is  wrong,  and  can  generally  be  avoided,  but  is  neverthe- 
less a  frequent  cause  of  disease  of  this  organ. 

Where  there  is  considerable  suppuration  of  the  upper  urinary 
passages  (renal  abscess,  pyelitis,  or  pyonephrosis),  the  acid  urine 
loaded  with  pus  has,  or  seems  to  have,  an  irritating  effect  on  the 
vesical  mucous  membrane,  and  in  some  instances  probably  lights  up 
a  cystitis,  and  certainly  aggravates  one  when  already  existing. 

Deposits  of  the  amorphous  phosphate  of  lime,  or  of  the  ammonio- 
magnesian  phosphate,  often  greatly  aggravate  and  render  serious  a 
previously  mild  cj^stitis,  but  seldom  if  ever  produce  acute  inflamma- 
tion in  a  healthy  bladder.  This  may  be  said  also  of  uric-acid  gravel 
and  other  crystalline  urinary  sediments,  they  being  at  most  only  able 
to  produce  some  hypersemia  of  the  membrane  with  a  little  excess  of 
the  mucous  secretion. 

Urine  which  is  already  decomposed,  or  decomposing,  as  I  have 
already  said,  can  produce  acute  cystitis  only  in  an  already  diseased 
bladder,  or  in  one  where  abrasions  of  the  epithelial  surface  exist. 

To  show  how  some  of  these  causes  may  combine  to  produce  cys- 
titis, let  me  take,  for  example,  the  bladder  of  a  pregnant  woman, 
which  has  for  some  time  shared  congestion  with  the  other  pelvic 
organs.  Retention  and  some  distention  of  the  bladder  occur  from 
some  cause ;  a  clumsy  physician  attempts  to  pass  a  metallic  catheter, 
and  does  it  roughly  and  rapidly,  and  relieves  the  viscus  of  its  con- 
tents. A  slight  catarrh  of  the  mucous  membrane,  the  surface  of 
which  is  somewhat  abraded,  ensues.  By  the  catalytic  action  of  the 
mucus  present  in  it,  the  urine  is  rapidly  decomposed.  The  decom- 
position is  often  aided  by  germs  introduced  with  the  catheter.  Car- 
bonate of  ammonia,  being  set  free  from  the  broken-down  urea,  as- 
sists in  alkalizing  the  fluid,  precipitating  the  amorphous  phosphates 
thereby,  and  forming,  with  the  phosphate  of  magnesia  already  pres- 
ent, the  ammonio-magnesian,  or  triple  phosphate.  The  urine  is 
further  alkalized  by  the  alkali  of  the  mucus.  The  bladder-walls  not 
having  fully  regained  their  tone,  a  little  decomposed  urine  remains 
after  each  micturition,  and  aids  in  decomposing  that  which  is  next 
secreted,  and  would  otherwise  be  normal.  The  mucus  increases  in 
amount,  the  ammonia   is  more  rapidly  set  free,  and  the  mucous 


734  DISEASES  OF   WOMEN. 

membrane  more  and  more  irritated,  until  a  true  acute  cystitis  is  set 
up.     Such  cases  are  of  almost  daily  occurrence. 

The  decomposed  urine  alone,  however,  produced  witiiout  the 
overdistention  or  without  the  abrasion  would  not  have  occasioned  a 
true  acute  cystitis,  but  might  possibly  by  slow  gradations  have  worked 
up  a  subacute  cystitis.  The  rule,  if  it  may  be  called  such,  is  the 
one  that  I  have  already  given — viz.,  that  some  abnormality  of  the 
urinary  organs  (as  catarrh)  almost  invariably  precedes  urinary  de- 
composition. 

3.  Inflammation  of  Adjacent  Organs. — Acute  cystitis  may  arise 
from  the  exten^^ion  of  inflammation  from  neighboring  organs,  as  in 
vaginitis,  metritis,  uterine  and  vaginal  cancer,  extra-uterine  pregnancy, 
abscesses  of  the  colon  or  other  organs  opening  into  the  bladder,  pelvic 
peritonitis,  cellulitis,  etc.  Gpnorrhfjeal  inflammation  of  the  urethra 
may  extend  to  the  bladder.  As  gonorrhoea  of  the  female  urethra  is 
comparatively  rare,  such  an  extension  is  seldom  seen.  When  it 
does  invade  the  urethra,  it  is  very  apt  also  to  extend  to  the  bladder, 
and  is  very  severe.  Inflammation  of  the  renal  pelves  and  ureters 
may  extend  to  this  organ,  and  cause  cystitis,  the  usual  course,  how- 
ever, being  from  the  bladder  to  the  ureters  and  the  kidneys. 

4.  Certain  diseases  of  the  general  system  affect  the  bladder, 
such  as  the  eruptive  fevers.  In  scarlet  fever,  and  measles  especially, 
I  have  noticed  that  the  mucous  membrane  of  the  bladder  suffers,  to 
some  extent,  like  the  mucous  and  tegumentary  tissues  elsewhere. 
Diseases  of  the  heart  and  liver  act  more  as  predisposing  causes,  by 
producing  chronic  vesical  congestion,  than  as  exciting  causes,  and 
when  they  do  produce  cystitis  it  is  usually  of  a  low  chronic  type. 
Old  age,  when  the  has  fond  is  greatly  deepened,  acts  more  as  a  pre- 
disposing cause,  by  allowing  the  collection  and  decomposition  of 
urine.  Paraplegia  and  other  affections  of  like  nature,  by  allowing 
overdistention  and  decomposition,  as  a  rule,  produce  cystitis,  but  of 
a  low  form. 

5.  Drugs,  Improper  Foods,  and  the  Virus  of  Gonorrhoea. — Of  all 
drugs,  cantharides  is  undoubtedly  the  most  active  in  producing  tnie 
acute  cystitis.  In  many  cases  it  produces  simple  irritation  and  hy- 
persemia,  stopping  short  of  actual  inflammation.  Arsenic  and  tur- 
pentine also  produce  irritation  and  active  hyperaemia,  but  seldom  if 
ever  go  further. 

Alcoholic  beverages  persisted  in  for  a  length  of  time  act  more  as 
predisposing  than  as  exciting  causes.  They  may,  however,  produce 
a  low  grade  of  cystitis,  or,  like  the  medicines  given  above,  light  up 
an  acute  process  in  an  already  diseased  vesical  membrane.     Dr.  A. 


ORGANIC   DISEASES   OF  THE   BLADDER.  Y35 

Jacobi  has  seen  aggravated  cases  of  cystitis  caused  by  tlie  free  and 
long-contiiuicd  use  of  large  doses  of  the  chlorate  of  potassa. 

The  various  foods  can  not  produce  acute  cystitis  in  a  healthy 
bladder,  but  may  aggravate  an  already  diseased  condition.  The 
prohibition,  th(!refore,  of  stimulating  condiments,  alcohol,  asparagus, 
and  onions,  in  these  diseases  will  at  once  suggest  itself.  I  have  al- 
ready spoken  of  gonorrhoea  as  a  cause  of  cystitis,  and  need  not  dwell 
on  it  here. 

M.  Eugene  Monod  ("  Annales  de  Gynecol.,"  May,  1880),  in  dis- 
cussing the  question  of  cystitis,  presents  the  following  conclusions : 

1.  The  urinary  symptoms  incident  to  pregnancy  proceed  from 
two  dilferent  causes,  to  each  of  wliich  there  corresponds  a  distinct 
clinical  group  of  symptoms.  The  first  group  receives  its  ex- 
planation from  the  pressure  produced  by  the  gravid  uterus,  which 
leads  to  retention  of  urine.  The  second  is  caused  by  vesical  con- 
gestion which  results  from  the  predisposition  of  the  bladder  to  in- 
flammation, owing  to  its  close  vascular  connection  with  the  uterus. 

2.  During  the  first  weeks  of  utero-gestation,  there  may  occur  a 
variety  of  acute  cystitis  which  is  unquestionably  caused  by  the  de- 
velopment of  pregnancy. 

3.  Immediately  after,  or  during  the  first  weeks  following  nor- 
mal delivery,  there  may  arise  a  variety  of  cystitis  which,  owing  to 
the  time  of  its  appearance,  deserves  to  be  called  post-puerperal  cys- 
titis. 

4.  The  anatomical  relations  between  uterus  and  bladder,  as  well 
as  their  vascular  interconnections,  account  for  the  frequency  of  ves- 
ical disorders  accompanying  many  uterine  maladies.  Certain  phys- 
iological changes  of  the  bladder  during  menstruation,  and  at  the 
time  of  the  menopause,  also  influence  the  establishment  of  bladder 
troubles.  Thus  there  is  seen  to  exist  a  whole  class  of  vesical  in- 
flammations belonging  only  to  women,  and,  contrary  to  the  gener- 
ally accepted  opinion,  cystitis  is  by  no  means  rare  in  women. 


CHAPTER  XLI. 

ORaANIC   DISEASES    OF    THE    BLADDER    (cONTINUEd). 

TREATMENT    OF    CYSTITIS  —  CROUPOUS    AND    DIPHTHERITIC 
CYSTITIS— CYSTITIS    WITH    EPIDERMOID    CONCRETIONS. 

Cystitis  requires  both  local  and  constitutional  treatment,  and 
withal  it  is  a  troublesome  disease  to  manage,  especially  in  its  chronic 
form.  The  constitutional  treatment  consists,  first  of  all,  in  so  regu- 
lating the  character  of  the  urine  that  it  shall  be  unirritating  to  the 
diseased  organ.  Pain  and  vesical  tenesmus  should  be  relieved  if 
possible.  The  skin  should  be  kept  in  a  healthy  and  active  condi- 
tion and  the  bowels  regular  and  free,  in  order  to  prevent  all  strain- 
ing at  stool  and  secure  free  action  of  the  portal  circulation.  Free 
elimination  by  the  skin  and  bowels  will  give  the  kidneys  and  blad- 
der less  to  do.  To  overcome  existing  constipation,  saline  laxatives 
should  be  used.  A  glass  of  purgative  mineral  water,  given  an  hour 
before  breakfast,  answers  very  well  in  most  cases.  Cold-water  ene- 
mata  are  advised  by  good  authorities. 

Winckel  recommends  the  use  of  saline  laxatives,  pushed  to  a 
point  where  intestinal  hypersemia  is  produced  and  maintained  for  a 
time.  He  believes  that  the  blood  may,  in  this  manner,  be  to  a  cer- 
tain extent  diverted  from  the  bladder ;  and  I  am  of  the  belief  that 
the  practice  is  a  sound  one.  A  case  of  my  own  is  of  interest  as 
showing  the  benefit  effected  (supposably)  in  this  way.  A  lady  had 
catarrh  of  the  bladder  of  some  months'  standing,  which  I  had  been 
treating  in  the  usual  way,  with  only  slight  benefit.  She  was  one 
day  attacked  with  cholera  morbus  with  serous  purging  and  vomiting, 
the  former  almost  as  severe  as  that  of  Asiatic  cholera.  The  efi^ect, 
for  a  time  was  to  almost  suspend  the  action  of  the  kidneys.  AVhen 
she  recovered,  she  was  delighted  to  find  that  her  cystitis  had  left  her. 

Among  the  conditions  which  produce  irritating  urine,  and  hence 
tend  to  produce  cystitis  or  to  aggravate  it  if  it  already  exists,  are 
malnutrition  from  any  cause  and  the  strumous,  gouty,  and  rheu- 
matic  diatheses.     When  either   of  these  is   present  it  should  be 


ORGANIC   DISEASES   OF   THE   BLADDER.  737 

treated  for  the  general  good  of  the  patient  and  the  indirect  effect 
upon  the  bhidder. 

The  diet  of  natients  suffering  from  this  disease  must  be  care- 
fully regulated.  Milk  will  be  found  to  agree  excellently  in  most 
cases.  In  the  hands  of  Dr.  George  Johnson,  of  England,  an  exclu- 
sive milk  diet  has  cured  several  cases,  some  of  great  severity  and 
long  standing. 

He  says :  "  The  milk  may  be  taken  cold  or  tepid  and  not  more 
than  a  pint  at  a  time,  lest  a  large  mass  of  curd,  difficult  of  digestion, 
form  and  collect  in  the  stomach.  Some  adults  will  take  as  much  as 
a  gallon  in  the  twenty-four  hours.  With  some  persons  the  milk  is 
found  to  agree  better  after  it  has  been  boiled,  and  then  taken  either 
cold  or  tepid.  If  the  milk  be  rich  in  cream,  and  if  the  cream  disa- 
gree, causing  heartburn,  headache,  diarrhoea,  or  the  symptoms  of 
dyspepsia,  the  cream  may  be  partially  removed  by  skimming. 
Constipation,  which  is  one  of  the  most  frequent  and  troublesome  re- 
sults of  an  exclusively  milk  diet,  is  to  some  extent  obviated  by  the 
cream  in  the  unskimmed  milk.  When  the  vesical  irritation  and  ca- 
tai-rh  have  passed  away,  solid  food  may  be  combined  with  the  milk, 
and  a  gradual  return  made  to  the  ordinary  diet." 

I  have  tried  this  method  of  treatment  in  several  instances  with 
decided  benefit. 

I  may  briefly  state  that  the  bill  of  fare  usually  given  consists 
largely  of  fluid  foods,  as  milk,  yolk  of  egg,  soups,  and  beef  essence. 
Lean  meat  in  small  amount,  and  other  solid  or  semi-solid  foods  that 
are  easily  digested  and  nutritious,  may  also  be  allowed.  The  cause, 
whatever  it  may  be,  should  be  removed,  if  possible ;  and  the  reme- 
dies must  be  adapted  to  the  stage  and  condition  of  the  inflammation. 
In  the  acute  stage  aggravated  by  exposure  to  cold,  diaphoretics 
should  be  freely  used,  and  the  patient  made  to  rest  as  quietly  as  pos- 
sible. Diuretics  should  be  given  if  the  urine  is  loaded  with  solid 
material,  and  the  alkaline  salts  are  to  be  preferred.  Vichy  water 
or  flaxseed  tea  with  citrate  or  nitrate  of  potash,  will  answer  very 
well  at  the  beginning  of  the  treatment.  In  using  such  salines,  it 
serves  admirably  to  give  them  in  an  infusion  of  buchu  in  case  the 
patient's  stomach  does  not  rebel  at  the  taste  of  it.  This  of  itself  is 
a  most  valuable  remedy  in  almost  all  bladder  affections.  Care  must 
be  taken,  however,  not  to  push  diuretics  too  far.  Sufliciont  to  bring 
the  urine  to  its  normal  proportions,  and  make  it  slightly  alkaline  if 
naturally  acid,  is  all  that  is  required. 

In  the  early  stages  of  acute  cystitis,  as  well  as  in  irritable  blad- 
der, Sidney  Einger  and  other  authorities  strongly  commend  the  use 
48 


738  DISEASES  OF   WOMEN. 

of  minim  doses  of  tincture  of  cantharides  repeated  every  hour,  and 
even  oftener,  but  I  have  not  seen  very  good  effects  from  its  use  in 
cystitis. 

One  or  two  leeches  to  the  anterior  vaginal  wall  may  be  tried, 
and  hot  applications  to  the  epigastrium  in  acute  cases.  To  relieve 
pain,  opium  is  indicated.  Dover's  powder  is  very  valuable,  and 
may  be  given  with  ordinary  doses  of  camphor.  If  there  is  any  ol)- 
jection  to  anodynes  given  in  this  way,  or  if  there  is  sympathetic 
rectal  tenesmus,  suppositories  of  morphia  and  belladonna  should  be 
used. 

While  I  have  said  that  opium  may  be  used  at  the  onset  of  acute 
cases,  and  to  relieve  the  suffering  in  old  eases  that  can  not  be  cured, 
I  must  impress  upon  the  mind  the  great  harm  that  may  come  from 
the  injudicious  use  of  this  drug  in  cystitis.  It  deranges  the  digestive 
organs  and  the  secretions  generally,  especially  that  of  the  kidneys ; 
and,  by  changing  the  quantitative  composition  of  the  urine,  renders 
it  irritating  to  the  bladder. 

In  some  cases,  where  frequent  urination  and  tenesmus  are  very 
severe,  owing  to  excessive  nervous  irritability,  twenty-grain  doses  of 
the  bromide  of  potassium,  every  four  hours  until  relieved,  act  very 
nicely  ;  indeed,  this  succeeds  in  cases  where  opiates  fail  entirely. 
Recently  I  have  used  hydrobromic  acid  and  find  that  it  acts  even 
better  than  the  bromide  of  potassium  in  some  cases. 

The  comparatively  new  drug,  eucalyptus  globulus,  is  worthy  of 
a  trial  in  obstinate  cases.  From  its  well-marked  benetieial  action  in 
albuminuria  and  other  affections  of  the  urinary  tract.  Dr.  AV.  Ander- 
son was  led  to  try  it  in  cystitis,  and  he  reports  it  as  decidedly  useful. 
Dr.  J.  J.  Mulheron,  of  Detroit,  gives  it  in  doses  of  twenty  minims  in 
subacute  cystitis  with  good  results.  As  this  remedy  has  tonic, 
antiperiodic,  and  antiseptic  properties,  it  might  be  especially  suit- 
able in  malarious  districts.  An  infusion  for  injection  in  cases  where 
the  urine  was  decomposed,  would  most  probably  give  good  results. 

Benzoic  acid  is  perhaps  the  drug  that  would  be  found  most  use- 
ful in  the  largest  number  of  cases.  It  often  seems  to  act  like  a  spe- 
cific, giving  speedy  and  permanent  relief.  It  may  be  given  in  about 
ten-grain  doses,  in  infusion  of  buchu,  three  or  four  times  a  day.  As 
the  acid  is  sparingly  soluble  in  cold  water,  an  equal  proportion  of 
borax  may  be  added  to  the  mixture.  To  insure  a  perfect  solution, 
one  may  prescribe  the  l)enzoate  of  ammonia,  which  in  the  same  dose 
acts  admirably,  and  is  more  palatable. 

In  the  more  advanced  stages  of  the  disease  remedies  are  used  for 
their  direct  effect  upon  the  mucous  membrane,  and  much  good  is 


ORGANIC   DISEASES   OF  THE   BLADDER.  739 

obtained  in  this  way.  The  drags  which  have  tlie  best  reputation  in 
urethritis  are  employed  in  cystitis.  Balsam  of  Peru  and  of  copaiba, 
oil  of  turpentine,  and  tar-water  are  the  most  important  of  this  class, 
and  should  be  given  in  capsules  in  the  same  way  as  for  gonorrhoea. 
Oil  of  sandal-wood  is  also  valuable  in  chronic  cases. 

When  the  pain  is  not  severe,  and  the  urine  is  loaded  with  mucus 
and  pus,  astringents  should  be  given.  Tannin  continued  for  a  con- 
siderable time  is  of  very  great  value.  Decoction  of  uva  ursi,  in 
half-ounce  doses,  may  also  be  used  for  this  purpose.  In  place  of 
these,  I  have  employed,  witli  occasional  good  effect,  a  mixture  com- 
posed of  two  ounces  fluid  extract  of  buchu,  one  ounce  tincture  of 
conium,  and  one  grain  and  a  half  sulphate  of  morphia,  giving  tea- 
spoonful  doses  every  three  or  four  hours.  When  pain  is  not  severe, 
the  morphine  should  be  omitted. 

Dr.  B.  A.  Segur,  of  this  city,  has  used  salicylate  of  soda  in  puru- 
lent cystitis,  and  found  that  the  quantity  of  pus  in  the  urine  rapidly 
decreased  under  the  use  of  this  remedy. 

Dr.  Sansom,  of  London,  found  that  the  administration  of  carbolic 
acid  and  the  sulpho-carbolates  to  animals  prevented  the  decomposi- 
tion of  urine,  although  he  could  not  detect  any  of  the  salt  in  the 
secretion.  He  gave  the  sulpho-carbolates,  and  afterward  collected 
and  preserved  the  urine,  which  after  six  months  had  not  decomposed. 
This  fact  should  be  kept  in  mind,  and  turned  to  account  in  cases 
where  there  is  a  tendency  to  decomposition  from  retention  or  other 
causes. 

An  English  physician  reports,  in  the  "  Canadian  Practitioner," 
that  he  has  met  with  no  case  of  offensive  urine  (intestinal -vesical 
fistula  excepted)  that  ten  or  twenty  grains  of  boracic  acid  given  every 
three  hours  would  not  cure.  All  these  remedies  may  be  tried  in 
cases  that  are  seen  early ;  but,  when  they  fail,  or  when  the  acute 
stage  of  the  trouble  is  long  past  before  advice  is  sought,  then  local 
treatment  must  be  employed.  The  bladder  should  be  washed  out, 
and  medicated  injections  used.  This  every  surgeon  will  feel  com- 
petent to  do,  no  doubt,  but  I  must  give  some  general  directions  as 
to  the  methods  of  manipulating,  as  I  feel  assured  that  much  of  the 
good  which  ought  to  come  from  this  kind  of  treatment  is  lost,  and 
harm  done  instead,  by  not  clearly  knowing  how  to  perform  this  op- 
eration, which  I  consider  both  difiicult  and  very  important. 

There  are  certain  rules  which  ought  to  be  carefully  obsei'ved  in 
washing  out  the  bladder.  The  catheter  should  be  sufficiently  soft 
and  flexible  to  be  incapable  of  injuring  the  bladder  or  urethra ;  it 
should  be  surgically  clean  ;  the  bladder  should  be  emptied  slowly, 


740 


DISEASES   OF    WOMEN. 


especially  when  withdrawing  the  last  of  its  contents,  otherwise  the 
bladder  will  contract  abruptly  upon  the  catheter,  and  be  injured 
thereby ;  instillations  should  be  made  very  slowly  (the  bladder  can 
not  be  rapidly  distended  without  injury),  and  the  quantity  used 
should  not  be  more  than  the  patient  can  tolerate  without  ])ain.  An 
ounce  is  sufficient,  and  much  less  will  suffice  if  more  gives  pain. 
When  the  quantity  which  can  be  borne  is  determined,  the  instillation 
and  withdrawal  of  that  quantity  can  be  repeated  until  the  desired 
effect  is  obtained. 

By  carefully  following  these  i*ules,  the  possible  benefit  of  local 
treatment  can  be  obtained.  Neglect  of  these  will  certainly  bring 
disfavor  upon  the  method.  Some  years  ago  I  employed  a  rather 
complicated  arrangement  for  washing  out  the  bladder,  consisting  of 
a  reiiux  catheter  with  a  fountain  attachment.  It  was  the  best  that 
I  could  lind  at  that  time,  but  I  have  long  ago  discarded  it  for  a  sim- 
pler and  much  better  instniment.  I  use  now  a  soft-rubl)er  catheter, 
having  attached  to  it  a  piece  of  rubber  tubing,  these  being  joined 
by  a  piece  of  glass  tubing,  the  whole  being  about  two  feet  in  length. 

A  small  glass  funnel  is 
introduced  into  the  end 
of  the  rubber  tube,  and 
this  completes  the  instru- 
ment (Fig.  229). 

This  is  used  as  a  cathe- 
ter to  empty  the  bladder 
of  urine,  and  then,  leav- 
ing it  still  in  place,  the 
washing  out  is  accom- 
plished by  pouring  the  so- 
lution to  be  used  into  the 
funnel,  and  raising  it  high 
enougli  to  make  it  floAV  into  the  bladder.  The  funnel  is  then  lowered 
to  permit  the  fluid  to  escape,  and  the  process  is  repeated  as  often  as 
may  be  necessary.  Any  desired  quantity  of  fluid  can  be  instilled  into 
the  bladder  at  any  degree  of  pressure  that  may  be  necessary  for  the 
comfort  of  the  patient,  and  the  fluid  can  be  drawn  off  slowly  or  rap- 
idly by  elevating  or  depressing  the  funnel.  It  is  very  important  not 
to  let  air  enter  the  bladder,  and  this  can  be  accomplished  by  letting 
the  patient  retain  a  few  drachms  of  urine  before  beginning  the 
treatment.  When  the  catheter  is  introduced,  and  the  urine  in  the 
bladder  drawn  off",  enough  of  the  urine  will  remain  in  the  catheter  to 
fill  it,  and,  by  filling  the  funnel  before  elevating,  the  fluid  used  will 


Fountain-sjTinge  for  washing  bladder. 


ORGANIC   DISEASES   OF   TOE   BLADDER.  741 

meet  the  urine  in  the  catheter  and  exchide  the  air.  In  case  the  blad- 
der is  empty,  the  catheter  should  be  hlled  before  introducing  it  into 
the  urethra,  and  tlie  air  will  be  exchided  in  that  way.  When  once 
the  process  of  washing  is  begun,  the  exclusion  of  air  is  easily  man- 
aged by  regulating  the  elevations  and  depressions  of  the  funnel,  so 
that  the  catheter  and  tube  will  be  kept  full  all  the  time. 

This  instrument  fulfills  all  the  indications  perfectly,  and  very 
little  practice  is  necessary  to  enable  one  to  use  it  with  facility.  When 
the  bladder  has  been  thoroughly  cleansed  in  this  way  of  all  inflam- 
matory products,  medicated  applications  may  be  made  in  the  same 
manner.  The  quantity  of  fluid  instilled,  the  length  of  time  it  is  left 
in  the  bladder,  and  the  time  occupied  in  making  the  instillation  and 
withdrawing  it  can  all  be  regulated  according  to  the  will  of  the  sur- 
geon and  the  toleration  of  the  patient. 

Much  care  should  be  taken  in  lubricating  the  catheter  so  that  it 
can  be  introduced  readily.  Oil  has  been  used  for  this  purpose, 
and  I  believe  that  some  surgeons  use  it  still.  Castile  soap  and  water 
or  vaseline  answers  much  better.  The  oil  decomposes,  and  renders 
the  catheter  unclean  unless  great  care  is  taken  to  wash  and  disinfect 
the  instrument  very  thoroughly.  In  fact,  it  is  hardly  possible  to 
keep  a  catheter  clean  for  any  length  of  time  if  oil  is  used  as  a  lubri- 
cant. Yaseline  is  best,  and,  if  that  is  not  at  hand,  then  soajD  will  an- 
swer. Cleansing  the  catheter  after  use  requires  more  than  a  passing 
notice.  I  have  found  that  if  a  soft-rubber  catheter  is  simply  washed 
after  use  in  the  ordinary  way — i.e.,  by  washing  it  off  with  warm 
water,  and  then  rinsing  it  in  a  mild  solution  of  carbolic  acid — say 
five  per  cent — it  becomes  very  foul.  A  catheter  used  in  that  way 
for  a  few  days  will  be  found  swarming  with  bacteria  on  the  inside. 
Such  an  instrument  is  dangerous,  and  should  never  be  used.  In  my 
private  hospital  each  patient  has  a  catheter  for  herself  alone,  and, 
when  she  is  through  with  it,  it  is  destroyed.  After  each  time  that  a 
catheter  is  used  it  is  well  washed  in  hot  water,  and  then  kept  in  a 
ten-per-cent  solution  of  carbolic  acid,  and  once  in  every  twenty-four 
hours  it  is  kept  for  fifteen  or  twenty  minutes  in  boiling  water.  With 
all  this  care  the  catheter  can  be  kept  clean  and  safe  for  use. 

Simply  washing  out  the  bladder  is  often  beneficial,  and  ought  to 
be  repeated  frequently.  It  should  always  be  done  before  using  any 
medicated  apj^lication.  Warm  water  alone  is  usually  employed,  but 
the  addition  of  chlorate  of  potash  or  common  salt  makes  it  less  u'ri- 
tating  to  the  bladder.  I  prefer  borax  or  common  table-salt,  using 
about  sixty  grains  to  the  pint  of  water.  It  is  generally  conceded 
that  salt  and  water  are  more  acceptable  to  serous  and  mucous  mem- 


742  DISEASES  OF  WOMEN. 

branes  than  any  other  fluid,  because  more  like  the  normal  secretion 
of  these  parts ;  but  I  have  not  found  it  any  better,  if  as  good,  as 
borax,  When  there  is  ulceration  or  suppuration,  carbolic  acid  and 
water  make  a  most  valuable  wash.  A  drop  to  the  drachm  or  there- 
about is  the  proper  propoi-tion. 

Having  prepared  the  bladder  for  local  applications  by  carefully 
washing  it  out,  the  material  to  be  used  may  be  selected  from  a  long 
list  of  remedies.  I  shall  mention  only  a  few — those  which  I  believe 
to  be  the  most  valuable.  I  need  hardly  say  that  anodynes  have  been 
tried  most  faithfully.  The  painful  character  of  the  disease  suggests 
their  use,  but  they  are  neither  reliable  nor  very  eifectual.  The 
mucous  membrane  of  the  bladder  is  not  intended  to  absorb,  and, 
therefore,  very  little  of  the  anodyne  effect  of  opium,  or  any  of  its 
preparations,  is  obtained  when  injected,  even  when  the  dose  is  very 
large.  Should  there  be  ulceration,  then  the  local  and  constitutional 
effects  of  morphia  will  be  produced  by  absorption.  Braxton  Hicks 
uses  one  or  two  grains  of  morphia  to  the  ounce  of  water  as  an  in- 
jection, allowing  the  patient  to  retain  it  as  long  as  possible,  and 
claims  good  results  from  its  use.  Remedies  which  produce  local 
ansesthesia  do  relieve  the  pain  to  some  extent,  but  not  altogether, 
by  any  anodyne  action,  such  as  we  get  from  opium  given  by  the 
mouth  or  rectum.  Cocaine  relieves  the  pain  for  a  short  time,  but 
not  long.  Its  chief  value  is  to  benumb  the  parts  so  that  curative 
applications  may  be  more  easily  made.  In  some  cases  it  acts  as 
an  irritant.  Chloral  hydrate  is  recommended  to  relieve  the  pain.  I 
have  used  it  in  solution,  ten  to  fifteen  grains  to  an  ounce  of  water, 
and  found  benefit  from  it. 

The  astringent  and  alterative  injections  most  beneficial  and  most 
commonly  used  are  nitrate  of  silver,  sulphate  of  zinc,  tannic  acid, 
and  acetate  of  lead.  My  rule  is  to  use  one  or  two  grains  of  either 
to  the  ounce  of  warm  water,  and  to  increase  the  quantity  if  no  good 
effect  comes  from  the  small  doses,  but  to  carefully  avoid  injections 
strong  enough  to  cause  much  pain.  Chlorate  of  potash  is  valuable, 
and  perchloride  of  iron  is  said  to  be  useful.  Infusion  of  hydrastis 
Canadensis  has  been  used,  and  great  virtue  is  claimed  for  it.  I  have 
tried  it,  and  believe  that  it  acts  well  in  some  cases,  but  still  it  fails, 
like  the  rest,  in  others.  When  the  urine  is  alkaline  and  offensive 
from  long  retention,  which  is  occasionally  the  case  in  prolapsus  of 
the  bladder,  then  nitro-hydrochloric  acid,  of  the  strength  of  two 
minims  to  the  ounce  of  water,  should  be  used.  Whenever  pain  is 
caused  by  any  of  these  astringent  injections,  morphia  should  be  used 
afterward,  as  directed  by  Braxton  Hicks. 


ORGANIC  DISExVSES   OF  THE   BLADDER.  743 

In  obstinate  cases  a  strong  solution  of  nitrate  of  silver  is  one  of 
the  most  reliable  remedies.  Twenty  grains  to  the  ounce  of  water 
has  been  used  with  great  benefit,  and  it  does  not  cause  as  much  pain 
as  might  be  supposed.  Very  small  quantities  only  can  l)e  used  at 
a  time — not  more  than  iive  or  ten  drops.  The  only  trouble  which 
I  have  experienced  is  in  being  sure  of  injecting  that  small  quantity 
and  no  more.  My  favorite  method  of  making  such  applications  to 
the  interior  of  the  bladder  is  by  instillation,  as  it  is  called.  1  take  a 
glass  tube  of  the  size  and  shape  of  a  No.  8  or  9  male  sound,  with  a 
small  rubber  bulb  attached  to  the  straight  end.  The  curved  point 
is  introduced  into  the  solution  to  be  used,  the  bulb  is  compressed  by 
the  thumb  and  finger,  and  then  relaxed,  which  draws  up  the  desired 
amount.  The  tube 
is  then  carried  into 
the  bladder,  and,  by 

.  Fig.  230.— Instillation  tube. 

again    compressmg 

the  bulb,  the  fluid  is  easily  deposited  in  the  organ  (Fig.  230). 

If  a  larger  quantity  is  to  be  used,  it  can  be  introduced  through 
the  instrument  used  for  washing  out  the  bladder.  In  fact,  I  seldom 
use  the  pipette  now  except  for  medicating  the  urethra. 

There  is  one  rule  that  should  be  followed  in  using  nitrate  of  sil- 
ver in  the  treatment  of  cystitis,  which  is  this :  If  a  strong  solution 
is  used,  only  a  few^  drops  should  be  employed,  and,  if  a  large  injec- 
tion is  made,  the  solution  should  be  mild.  I  am  indebted  to  Prof. 
John  W.  S.  Gouley  for  this  valuable  guide  in  the  use  of  this  remedy. 

Normal  urine  has  been  highly  recommended  as  an  injection  in 
cystitis.  The  urine  from  a  healthy  person  is  obtained  and  used  in 
the  same  way  as  the  other  injections  described.  I  have  always  looked 
upon  this  treatment  with  a  little  suspicion.  It  may  be  of  value  in 
cases  where  from  some  derangement  of  the  general  system  the  urine 
secreted  is  abnormal,  and  therefore  irritating  to  the  bladder,  and 
where  constitutional  treatment  can  not  remove  that  condition.  When 
the  urine  secreted  can  be  kept  in  a  normal  state,  it  must,  it  seems  to 
me,  be  as  acceptable  to  the  bladder  as  the  same  kind  of  urine  from 
another  person.  Theoretically,  one  would  expect  that  healthy  urine 
poured  into  the  bladder  from  the  kidneys  would  be  more  likely  to 
cm*e  cystitis  than  if  it  were  injected  through  the  urethra.  However, 
this  method  may  be  of  value ;  but  one  thing  is  certain — it  fails  like 
all  other  injections  in  certain  cases. 

Iodoform  has  been  used  locally  in  cystitis,  and  with  good  effect ; 
but  I  regret  to  say  that  I  have  not  used  it  enough  to  test  its  merits 
fully. 


744:  DISEASES  OF  WOMEN. 

One  great  obstacle  often  met  with  in  using  instillations  is  a  ten- 
der or  inflamed  urethra.  This  difficulty  1  have  recently  been  able 
to  overcome  by  using  cocaine.  It  is  appHed  as  follows :  I  take  a 
pipette  like  the  one  described  above  but  larger,  fill  it  with  cocaine 
solution,  and  introducing  the  tapering  part  of  it  into  the  meatus,  force 
the  solution  along  the  urethra  and  into  the  bladder.  This  often 
makes  the  rest  of  the  treatment  easy. 

Another  direct  method  of  treating  the  bladder  has  been  employed 
by  Dr.  Robert  Xewuian,  of  New  York,  w'ho  has  made  some  useful 
contributions  to  the  therapeutics  of  vesical  disease.  He  employs 
the  endoscope  of  Desormeaux  to  make  the  diagnosis,  and  makes 
direct  applications  to  the  diseased  parts  through  that  instrument.  In 
ulceration,  he  has  been  very  successful  in  his  practice.  He  applies 
a  solution  of  the  nitrate  of  silver  (twenty  grains  to  the  drachm  of 
water)  to  the  ulcerated  surface,  and  by  carefully  regulating  the 
amount,  finds  that  the  pain  is  less  than  when  a  weaker  solution  is 
used  in  the  ordinary  way.  I  have  done  the  same  thing  with  greater 
facility  by  using  the  endoscope  which  I  have  described.  The  in- 
strument is  introduced,  and  the  ulcerated  part  found ;  the  glass  tube 
is  drawn  out,  and  the  application  made  directly  to  the  diseased  part, 
through  the  rubber  speculum.  Forcible  and  extreme  dilatation  of 
the  urethra  has  been  advocated  in  the  treatment  of  cystitis  by  many 
surgeons  otherwise  well  informed.  Within  the  past  few  j'ears  the 
medical  journals  have  contained  the  histories  of  many  cases  of  cys- 
titis said  to  have  been  cured  by  this  operation.  This  is  all  quite  er- 
roneous. Cystitis  can  no  more  be  cured  by  dilating  the  urethra 
than  could  a  gastritis  be  cured  by  dilating  the  sphincter  aui.  It  is 
a  fact  that  if  the  urethra  be  destroyed  by  overdistention,  inconti- 
nence will  follow,  and  the  perfect  drainage  of  the  bladder  may 
cure  the  inflammation  ;  but  verily  the  cure  is  worse  than  the 
disease.  I  am  sure  that  the  mistake  in  regard  to  the  value  of  this 
operation  in  cystitis  comes  from  its  having  been  practiced  in  cases  of 
acute  cystitis  which  would  have  ended  in  recovery  without  any  sur- 
gical treatment,  and  again  in  cases  of  inflammation  of  the  upper 
third  of  the  urethra  which  have  been  mistaken  for  cystitis.  On  the 
one  hand  the  operation  gets  the  credit  of  curing  a  disease  which 
cured  itself,  and  on  the  other  of  curing  a  disease  which  did  not  ex- 
ist. It  will  be  observed  that  in  the  cases  which  I  give  at  the  close 
of  this  section,  the  urethra  was  dilated  with  no  benefit,  and  to  these 
I  could  add  many  others  which  were  treated  in  the  same  way  with  a 
like  result. 

All  the  means  of  treatment  yet  described  will  fail  in  some  of  the 


ORGANIC   DISEASES   OF  THE    BLADDER.  745 

worst  cases  of  chronic  cystitis.  Indeed,  this  has  led  to  the  last  re- 
sort, as  I  look  upon  it,  namely,  cystotomy  for  the  establishment  of 
vesico-vaginal  fistula  to  drain  the  bladder  and  set  it  at  rest.  The 
perfect  rest  obtained  by  the  urine  flowing  out  through  the  fistula  as 
soon  as  it  enters  from  the  ureters  places  the  inflamed  surfaces  in  a 
condition  to  recover,  and  the  patient  is  relieved  from  the  constant 
pain  and  the  torments  of  urinating  every  few  minutes  night  and 
day. 

This  is  certainly  a  great  triumph,  and  is  especially  applicable  in 
cases  that  are  incurable  by  all  other  means.  Indeed,  it  is  adapted  to 
cases  which  are  incurable  by  this  operation,  because  it  gives  relief 
from  pain,  and  makes  the  last  days  of  an  incurable  sufferer  tolerable. 
Dr.  Willard  Parker,  I  believe,  was  the  first  to  do  cystotomy  for 
the  cure  of  cystitis  in  the  male,  and  Dr.  T.  A.  Emmet  adopted  the 
operation,  and  has  practiced  it  extensively  among  his  female  patients. 
In  fact,  he  has  become  a  zealous  advocate  of  this  method  of  treating 
cystitis.  In  his  book  on  gynecology,  in  speaking  of  cystitis  in 
women,  he  says  that  our  management  of  this  affection  is  limited  to 
one  procedure,  and  that  is  vaginal  cystotomy. 

Such  a  dogmatical  statement  is  quite  in  opposition  to  facts  well 
known  to  many  in  the  profession.  Drainage  by  vesico-vaginal  fist- 
ula is  neither  the  surest,  safest,  nor  simplest  method  of  treating  cys- 
titis in  women,  but  only  one  method  to  be  employed  in  those  rare 
cases  which  do  not  yield  readily  to  other  means. 

While  writing  on  this  subject  some  years  ago,  I  obtained  from 
one  of  the  resident  surgeons  of  the  Woman's  Hospital  the  statement 
that  cystotomy  was  performed  for  the  relief  of  cystitis  on  seventeen 
cases  in  that  institution,  and  that  four  were  cured  and  thirteen  im- 
proved. This  shows  about  twenty-four  per  cent  of  recoveries,  and 
this  I  stated  in  my  book  on  "  Diseases  of  the  Bladder."  Dr.  Em- 
met in  his  book  on  gynecology  objects  to  this  statement  of  mine  as 
not  being  in  accordance  with  a  published  report  of  the  Woman's 
Hospital.  The  report  referred  to  was  not  published  at  the  time  that 
I  prepared  my  manuscript,  nor  did  I  see  it  until  after  my  book  was 
published.  I  presumed  that  the  interne  of  the  hospital  gave  me  a 
correct  report,  but  be  that  as  it  may.  Dr.  Emmet's  own  statistics  (as 
given  in  his  book,  page  788)  of  the  hospital  practice  are  less  favor- 
able to  cystotomy  for  the  cure  of  cystitis  than  those  quoted  by  me. 
They  show  but  about  twenty  per  cent  of  recoveries,  whei-eas  my 
statement  obtained  from  the  interne  was  twenty-four  per  cent.  This 
shows  that  if  I  made  a  mistake  it  was  in  favor  of  the  operation  ;  or 
else  if  I  was  correctly  informed  of  the  results  of  that  operation  at 


74G  DISEASES  OF   WOMEN. 

that  time,  then  the  subsequent  hospital  experience  of  Dr.  Emmet 
has  been  more  unsatisfactory.  Dr.  Emmet's  method  of  making 
the  fistulous  opening  is  by  dividing  the  vesico- vaginal  septum 
with  the  scissors,  and  then  introducing  a  glass  tube  to  keep  the 
opening  from  closing.  This  is  the  most  difficult  way  of  operating 
and  the  most  painful  to  the  patient  afterward.  The  wearing  of 
this  tube  has  been  a  torture  to  those  that  I  have  seen  u-sing  it. 
There  are  two  other  methods  of  operating.  One  is  to  make  the 
opening,  and  then  stitch  the  mucous  membrane  of  the  bladder  to 
the  raucous  membrane  of  the  vagina,  thus  preventing  the  closing 
of  the  opening,  and  at  the  same  time  enabling  the  edges  of  the 
wound  to  heal  in  a  short  time,  a  great  gain  in  itself.  The  other 
method  is  to  make  the  opening  with  the  galvano-  or  thermo-cau- 
tery.  Dr.  M.  A.  Fallen  was  the  first  to  operate  with  the  thermo- 
cautery. This  is  what  he  savs  about  it :  "  The  main  difficulty 
hitherto  has  been  to  keep  the  incision  open  after  the  use  of  the 
scissors  or  knife.  Artificial  means  must  be  resorted  to,  such  as  an 
India-rubber  tube  passed  from  the  urethra  through  the  opening, 
which  is  annoying  and  painful ;  or  a  glass  button  introduced, 
which  is  difficult  to  retain,  and  when  retained  is  apt  to  beget  vesical 
tenesmus.  I  believe  that  the  use  of  the  actual  cautery  at  a  red 
heat  will  be  found  to  answer  all  purposes.  If  the  platinum  tip 
is  at  a  white  heat  it  cuts  through  too  rapidly,  and  we  are  apt  to  have 
as  much  haemorrhage  as  with  the  knife  or  scissors.  Haemorrhage  is 
sometimes  quite  serious  after  incision  of  the  vesico-vaginal  septum, 
particularly  if  the  scissors  or  knife  strike  the  tortuous,  enlarged 
veins,  often  ramifying  upon  or  under  the  mucous  membrane  of 
the  bladder.  If  the  platinum  tip  of  the  cautery  be  heated  to  a 
white  heat,  it  cuts  through  as  rapidly  as  the  knife,  and  therefore  the 
haemorrhage  is  to  be  expected  ;  besides,  the  thin  pellicle  of  slough 
following  the  white-heat  tip  soon  peels  ofi,  and  union  might  ensue. 
To  avoid  both  bleeding  and  contraction,  the  red-heat  tip  should  be 
slowly  passed  along  the  site  of  the  proposed  opening,  dividing  first 
the  mucous  membrane  of  tlie  vagina,  and  then  resting  for  a  moment 
or  so  to  allow  the  adjacent  vessels  to  contract  and  become  throm- 
botic. The  submucous  connective  tissue  is  then  burned,  and  after- 
ward the  bladder-wall  itself.  Extreme  delicacy  of  manipulation  is 
required  upon  the  part  of  the  surgeon,  lest  he  burn  directly  into 
the  cavity  of  the  bladder,  which  should  be  avoided  if  he  wants  to 
make  sure  of  a  result  that  will  prevent  hgemorrhage,  contraction, 
and  subsequent  union. 

'•  The  care  after  an  operation  of  this  kind  consists  in  daily  cleans- 


ORGANIC   DISEASES   OF   THE   BLADDER.  747 

ing  the  bladder  thoroughly  with  demulcent  warm  fluids,  such  as 
starch  or  flaxseed  water.  The  pain  in  the  bladder  following  the 
burning  is  comparatively  slight,  and  usually  subsides  within  thirty-six 
or  forty-eight  hours." 

Dr.  John  Byrne,  of  Brooklyn,  operates  in  a  very  easy  and  satis- 
factory manner.  He  has  a  forceps,  one  blade  of  which  is  intro- 
duced into  the  bladder  and  the  other  into  the  vagina  to  grasp  the 
vesico-vaginal  septum.  The  blade  in  the  vagina  is  fenestrated  and 
the  blade  in  the  bladder  is  grooved.  The  thermocautery  knife  is 
introduced  through  the  fenestrum  of  the  forceps  and  the  septum  is 
divided,  the  knife  being  guided  by  the  forceps. 

This  method  makes  the  operation  simple  and  easy,  and  the  after 
treatment  is  also  greatly  simjDlified, 

One  serious  drawback  to  cystotomy  is  the  incontinence  which 
keeps  the  patient  in  such  an  uncomfortable  state  by  the  constant 
trickling  of  urine  from  the  fistula,  I  tried  to  obviate  this  trouble 
to  some  extent  by  using  a  hollow-globe  pessary,  made  of  hard  rub- 
ber, with  a  tube  attached  to  it.  The  globe  is  perforated  with  nu- 
merous small  holes  all  around,  except  for  about  half  an  inch  from 
where  the  tube  begins.  The  globe  is  introduced  into  the  vagina, 
and  the  tube  projects  through  the  introitus.  The  urine  collects  in 
the  globe,  and  escapes  through  the  tube ;  and  by  attaching  a  piece 
of  flexible  tubing  to  it  the  urine  can  be  conveyed  into  a  vessel. 
When  the  introitus  vulvae  is  small  and  the  sphincter  vaginae  perfect, 
this  answers  very  well,  especially  during  the  night,  when  the  patient 
is  in  the  horizontal  position.  When  worn  during  the  day,  it  is  ne- 
cessary to  have  a  rubber  bag  attached  to  the  leg  of  the  patient  to  act 
as  a  receptacle. 

Encouraged  by  my  success  with  the  globe-pessaiy,  I  had  another 
made,  shown  in  Fig.  231.  It  is  the  ordinary  Smith's  pessary,  with 
an  oblong  cup  on  the  upper 
anterior  portion  of  it,  which  ^- 
fits  over  the  fistula,  and  collects 
the  urine  and  guides  it  out  to 
a  urinal.  In  artificial  fistula, 
made  in  the  center  of  the  va- 
gina,   this    pessary   answers   a 

,        111  Fig.  231. — Skene's  urinal  cup-pessary,     a,  rep- 

most  valuable  purpose.  ^  ^^^^^^^  ^^^  p„,terior   portion   winch  sur- 

I    was    led     to    devise  this            rounds  the  cervix  uteri ;  6,  the  cup  ;  and  c, 

<•■!'•              .  •       .  'J.!              the  tube  which  conveys  the  urine  from  the 

way  of  rehevmg  patients  with         ^„p  ^^ ,,,,  ^„.i„^, 
vesico-vaginal   fistulas  by  hav- 
ing one  under  my  care  who  was  in  no  condition  to  be  operated  on 


748  DISEASES  OF   WOMEN. 

for  the  cure  of  fistula,  owing  to  general  ill-health.  She  also  had 
severe  vulvitis,  and  the  urine  constantly  passing  over  the  iriHamed 
surface  drove  her  almost  insane.  Her  suffering  was  terrible  ;  so  to 
relieve  her  until  I  could  operate  I  had  made  the  perforated  stem 
globe-pessary,  or  whatever  one  may  see  tit  to  call  it. 

I  come  now  to  what  I  believe  to  be  another  important  part  of 
the  treatment  of  these  obstinate  cases.  I  allude  to  drainage  by 
means  of  the  self-retaining  catheter.  Years  ago  I  had  a  very  trou- 
blesome case  of  cystitis,  which  I  faithfully  tried  to  relieve  by  all  the 
means  at  my  command,  but  without  success.  My  patient  was 
obliged  to  urinate  every  fifteen  or  twenty  minutes,  day  and  night, 
and  the  pain  and  want  of  rest  were  fast  wearing  her  out.  In  the 
hope  of  securing  rest  at  night  I  introduced  a  Situs's  self-retaining 
cathet2r  with  a  rubber  tube  attached,  to  convey  the  water  to  the 
urinal.  The  result  was  very  gratifying.  She  could  sleep  well,  and 
gained  in  health  and  strength  rapidly,  and  the  cystitis  gradually 
improved.  Since  that  time  I  have  resorted  to  drainage  by  catheter 
in  cases  which  resisted  the  ordinary  treatment. 

A  description  of  this  plan  of  treatment  will  be  found  in  the 
"  Proceedings  of  the  New  York  Obstetrical  Society,"  recorded  in 
the  "American  Join*nal  of  Obstetrics,"  for  February,  1874.  This 
method  has  been  successfully  practiced  by  Hunter  McGuire,  a  com- 
plete history  of  his  case  being  published  in  the  "  Richmond  and 
Louisville  Medical  Journal "  for  June,  1874.  Dr.  McGuire  took  a 
piece  of  tubing  about  tw^elve  inches  long,  and  made  holes  in  about 
four  inclies  of  the  end  of  it  with  a  shoemaker's  punch.  He  passed 
a  silver  tube  into  the  bladder,  and  then  pushed  the  gum  tube  through 
it  until  the  perforated  four  inches  were  coiled  in  the  bladder.  This 
was  retained  in  place  by  tapes  fixed  to  the  tube  and  to  a  bandage 
passed  around  the  patient's  body.  The  tube  became  obstructed  by 
mucus,  but  was  easily  cleared  by  injecting  warm  water  thi'ough  it. 
But  this  long  piece  of  tubing  being  frequently  expelled  by  the  blad- 
der, the  doctor  tried  a  shorter  piece,  and  found  it  was  more  readily 
retained.  The  patient  after  a  time  went  about  and  attended  to  her 
household  duties  while  wearing  the  tube,  and  in  about  four  mouths 
made  a  perfect  recovery. 

This  method  of  drainage  is  an  improvement  on  Sims's  catheter, 
but  still  is  not  all  that  we  require.  Since  my  first  case  I  have  found 
that  a  good  self -retaining  catheter  for  this  purpose  is  Holt's,  made 
of  perfectly  flexible  rubber,  and,  in  place  of  an  eye  in  the  point,  is 
cut  into  strips  near  the  end,  and  made  to  spread  out  like  an  umbrella 
(Fig.  232). 


ORGANIC   DISEASES   OF   THE   BLADDER. 


749 


Another  instrument  for  drainage  is  a  catheter  devised  by  Prof. 
Goodman,  and  described  in  the  "  Richmond  and  Louisville  Medical 
Journal,"  for  February, 
1S69,  as  being  used  in  the 
treatment  of  vesico-vaginal 
fistula,  and  I  have  recently 
learned  that  he  has  used  it 
for  years  in  treating  cystitis. 
The  following  is  Dr.  Good- 
man's description  of  his  cath- 
eter :  ''  It  is  about  two  inches 
in  length,  and  bent  to  cor- 
respond to  the  curvature  of 

the  nrethra  ;  at  the  lower  or  ^i«-  232.— Holt's  catheter,  with  its  modification, 
external  end  there  is  a  button  ten  sixteenths  of  an  inch  in  diameter, 
and  at  the  other,  or  external,  end  a  shouldered,  cup-shaped  expan- 
sion, varying  from  five  sixteenths  to  seven  sixteenths  of  an  inch  in 
diameter,  and  beveled  on  the  convex  aspect  of  the  instrument,  in 
order  to  make  it  easier  of  introduction,  and  perforated  with  a  num- 
ber of  small  holes.  The  stem,  intervening  between  these  two  por- 
tions, is  one  and  one  half  inch  in  length,  a  quarter  of  an  inch  in 
diameter,  with  as  large  a  bore  as  is  compatible  with  the  requisite 
strength.  This  catheter  is  self-retaining  in  all  positions  of  the  pa- 
tient ;  first,  by  reason  of  the  bulb  at  its  upper  extremity,  which 
passes  beyond  the  urethra  into  the  bladder ;  second,  on  account  of 
its  curved  shape  ;  and  third,  in  consequence  of  the  button  being 
overlapped  and  grasped,  as  it  were,  by  the  vulva.  At  the  lower  end 
there  is  a  slight  projection,  or  knob,  over  which  an  India-rubber  tube 
may  be  slipped,  this  being  inserted  into  a  bottle  at  night,  or  into  a 
urinal  when  the  patient  is  up ;  her  person  may  thus  be  kept  per- 
fectly clean."  I  like  this  instrument  for  the  purpose  of  draining  the 
bladder,  when  the  j)atient  can  tolerate  it;  but  I  believe  that  the 
sharp  point  of  the  conical  end  which  rests  in  the  bladder  is  objec- 
tionable, and  I  can  see  no  good  reason 
for  having  it  so.  I  had  the  point 
made  larger  and  I'ounder  (Fig.  223), 
and  found  that  it  answered  certainly 
as  well,  and  was  easier  to  introduce. 
In  drainage  by  any  method  it  must 
be  remembered  that  the  instrument  should  be  frequently  removed 
and  cleaned,  and  the  bladder  occasionally  be  washed  out  at  the  same 
time. 


Fig.   233. — Skene's   modification   of 
Goodman's  self-retaiuinc;  catheter. 


750  DISEASES  OF   WOMENT. 

Fortunate  it  is  that  we  have  this  method  of  treatment  now  at  our 
command.  By  this  means  we  can  restore  to  health  and  comfort 
many  of  those  cases  which  luive  hitherto  been  considered  hopeless. 

I  believe  tliat  a  normal  condition  of  the  urethra  is  a  prerequisite 
to  drainage.  When  there  is  tenderness  of  the  urethra,  the  patient 
can  not  tolerate  the  catheter ;  this  form  of  treatment  would  be  more 
popular  if  this  point  had  not  been  overlooked. 

Where  there  is  haemoiTliage  into  the  bladder,  the  rules  already 
given  are  to  be  followed. 

In  cases  of  exfoliation  of  the  whole  or  a  part  of  the  mucous  mem- 
brane of  the  bladder,  and  the  organ  is  evidently  trying  to  expel  its 
contents,  the  urethra  should  be  sufficiently  dilated  to  allow  the  mass 
to  pass,  or  it  may  be  removed  by  the  forceps,  if  this  can  be  done 
without  force.  After  its  extraction  antiseptic  and  disinfectant  meas- 
ures should  be  resorted  to.  Injections  of  lime-water,  Aveak  solutions 
of  carbolic  acid  or  salicylic  acid  should  be  used,  and  the  organ 
washed  out  once  or  twice  daily  with  warm  water.  Above  all,  mine 
should  not  be  permitted  to  remain  in  the  tender  organ  for  any  length 
of  time. 

In  passing  the  catheter,  especially  in  cases  where  the  bladder  is 
bound  to  neighboring  organs,  care  should  be  taken  to  let  no  air  enter, 
for  Winckel  has  seen  vesical  catarrh  follow  its  introduction,  and 
makes  it  a  point,  even  after  using  Rutenberg's  apparatus,  to  wash 
out  the  organ  with  some  antiseptic. 

Prognosis. — In  acute  cystitis  occurring  in  a  healthy  subject  the 
outlook  is  good,  recovery  being  usually  attained  in  from  one  to  three 
weeks.  When  occm'ring  in  the  course  of  pregnancy,  or  after  de- 
livery, the  prognosis  is  not  so  good,  there  being  a  tendency  for  the 
diseasB  to  become  chronic,  and,  even  if  cured,  it  leaves  a  weak  state 
of  the  organ  afterward.  The  prognosis  in  diphtheritic  and  croupous 
cystitis  depends  mainly  on  the  systemic  disorder,  and  is,  therefore, 
grave. 

AVhen  due  to  displacements  of  the  gravid  uterus,  the  prognosis 
will,  of  course,  depend  on  the  abihty  to  replace  the  womb.  In  can- 
cer of  the  womb,  vagina,  anterior  vaginal  wall,  or  of  the  bladder  it- 
self, the  prognosis  is  the  same  as  in  malignant  disease  generally.  In 
chronic  cystitis,  with  ulceration,  the  prognosis  is  very  serious ;  for, 
with  the  tendency  to  haemorrhage,  extension  to  the  peritonaeum, 
perforation,  blood-poisoning,  with  low  systemic  condition,  extension 
to  the  renal  pelves,  and  destruction  of  one  or  both  kidneys,  a  fatal 
termination  comes  sooner  or  later,  and  may  come  when  we  least 
expect  it. 


ORGANIC  DISEASES  OF  THE  BLADDER.  T51 

About  one  half  of  the  cases  of  exfoliation  of  the  vesical  mucous 
membrane  have  recovered.  Gangrenous  inflammation,  involving,  as 
it  usually  does,  all  the  coats  of  the  bladder,  is  tlie  most  speedily  and 
certainly  fatal  of  all  the  forms  of  cystitis. 

Hygiene. — There  are  certain  points  to  be  considered  in  the  man- 
agement of  all  cases  where,  from  certain  circumstances,  vesical  dis- 
ease is  to  be  expected,  and  also  where  it  already  exists. 

In  pregnant  women,  where  the  pelvic  organs  are  constantly  tend- 
ing to  congestion,  attention  should  be  given  to  the  patient's  circula- 
tion ;  friction  to  the  legs,  feet,  and  arms ;  daily  warm  baths ;  mod- 
erate exercise,  alternated  with  periods  of  rest  in  the  recumbent 
position,  and  astringent  or  saline  vaginal  injections  should  be  em- 
ployed. Upon  the  least  suspicion  of  malposition  of  the  uteras,  that 
organ  should  be  examined,  and,  if  malposed,  replaced.  The  diet 
should  be  bland  and  unirritating,  yet  nourishing,  and  any  indigestion 
corrected  as  speedily  as  possible.  An  occasional  saline  laxative  will 
prove  of  use  when  there  is  constipation.  Tonics  will  be  found  serv- 
iceable in  some  instances. 

In  women  not  pregnant,  where  there  is  a  tendency  to  vesical  dis- 
ease, the  same  plan  should  be  followed,  with  the  addition  of  injec- 
tions of  water,  as  hot  as  can  be  borne,  into  the  vagina  every  night, 
as  recommended  by  Dr.  Emmet,  l^ot  less  than  a  gallon  should  be 
used.  Where  from  any  cause  retention  exists,  or  there  is  a  tendency 
thereto,  the  urine  should  be  drawn  carefully  with  a  soft  catheter, 
well  soaped,  being  sure  that  the  catheter  is  perfectly  clean,  and  that 
no  air  is  permitted  to  enter  the  viscus  for  the  reasons  already  given. 
Winckel  believes  that  in  every  institution  for  lying-in  women  each 
patient  should  either  have  a  new  catheter  assigned  to  her,  or  one 
rendered  absolutely  clean  by  some  efficient  chemical  process.  *  To 
the  enforcement  of  this  rule  Winckel  attributes  the  great  exemption 
from  vesical  inflammation  enjoyed  by  the  patients  in  the  Dresden 
House  for  Child-bearing  Women, 

I  must  fully  indorse  the  teaching  of  this  great  authority.  I  have 
seen  so  much  bladder  trouble  brought  on  by  the  careless  use  of  foul 
catheters  that  I  have  come  to  look  upon  clumsy  operators  and  un- 
clean instruments  as  the  most  common  causes  of  cystitis. 

In  weakness  of  the  detrusor  vesicae  (which  is  not  an  uncommon 
affection  in  pregnant  women),  Winckel  has  achieved  great  success 
with  injections  of  simple  warm  or  medicated  water  into  the  bladder. 

In  irritable  bladder,  -sWth  a  tendency  to  congestion,  a  solution  of 
borax  may  be  injected  with  good  results. 

Every  woman,  even  at  the  risk  of  disturbing  company  or  neglect- 


752  DISEASES  OF   WOMEN". 

iug  important  duties,  should  evacuate  the  bladder  regularly,  and 
never  long  resist  the  desire  to  urinate. 

ILLUSTKATTVE   CASES. 

Chronic  Cystitis  with  Intermittent  Drainage  ;  Death  from  Perfora- 
tion of  the  Bladder. — The  patient  was  under  my  care  fi-oiii  xS  ovember 
0,  18G9,  to  February  10,  1870,  while  suffering  from  a  (cystitis,  which 
began  after  one  of  her  confinements  several  years  before.  At  that 
time  she  had  a. well-marked  cystitis  of  the  punilent  variety.  She 
was  treated  by  injections — the  method  in  vogue  at  that  time — with 
some  benefit.  I  also  employed  drainage  part  of  the  time  by  intro- 
ducing a  catheter  in  the  evening,  and  letting  it  remain  all  night. 
This  gave  her  great  relief,  and  permitted  her  to  sleep — a  blessing 
which  she  had  not  enjoyed  for  sev^eral  years.  She  was  improving 
in  her  general  health,  although  her  local  disease  remained  about  the 
same,  or  at  least  only  a  little  improved.  She  expected  to  return  for 
further  treatment,  but,  her  husband  becoming  paralyzed,  she  was 
obliged  to  give  up  the  care  of  herself  to  look  after  her  family.  From 
that  time  up  to  July,  1882,  she  continued  to  suffer  tortures  during 
the  day,  while  she  was  obliged  to  be  up  and  around  attending  to  her 
household  duties.  At  night  she  obtained  relief  by  wearing  tlie  cath- 
eter, which  she  had  continued  to  use  ever  since  she  was  taught  to  do 
so,  twelve  years  before.  Her  sufferings  were  almost  beyond  descrip- 
tion, but,  having  an  iron  constitution  and  extraordinary  will-power, 
she  managed  to  live  until  the  summer  of  1882.  During  June  and 
July  of  that  year  she  failed  more  rapidly.  Having  heard  of  dilata- 
tion of  the  urethra  as  a  cure  for  cystitis,  she  urged  her  physician  to 
try  that  operation.  He  did  so,  and  repeated  the  operation  one  week 
later.  The  only  effect  of  this  treatment  (as  stated  in  the  notes  of 
her  history,  which  I  obtained)  was  to  reduce  the  number  of  evacua- 
tions from  one  hundred  and  sixty  to  one  hundred  in  twenty-four 
hours.  Her  physician  then  injected  her  bladder  in  the  hope  of  re- 
lieving the  inflauimation  and  also  overcoming  the  contraction,  which 
was  very  marked.  Immediately  after  the  first  and  only  injection  she 
was  seized  with  violent  abdominal  pains,  and  rapidly  developed  a 
peritonitis,  which  proved  fatal  on  the  second  day. 

On  post-mortem  it  was  found  that  the  bladder  was  adherent  to 
all  the  viscera  around  it,  the  result,  no  doubt,  of  a  former  pericys- 
titis. Upon  the  posterior  wall  of  the  bladder,  and  directly  opposite 
the  urethra,  there  was  a  nipple-like  projection  outward,  with  an 
opening  at  its  apex  large  enough  to  admit  a  lead-pencil.  This  pro- 
tuberance had  been  produced  by  the  long  use  of  the  hard  catheter. 


ORGANIC   DISEASES   OF   THE   BLADDER.  Y53 

The  instrument  liad  worn  tliroiigh  the  inner  walls  of  the  bladder 
until  the  parts  had  become  less  resistant ;  it  then  pushed  the  remain- 
ing muscular  tissue  and  peritonsenm  outward,  and  formed  the  nipple- 
like projection.  At  the  time  of  the  fatal  attack,  the  catheter  had 
made  its  way  through  all  the  coats  of  the  bladder  except  the  thick- 
ened peritonaeum.  The  rupture  of  the  peritonaeum  was  caused  by 
the  injection.  That  was  the  belief  of  the  physician  in  attendance, 
and  the  history  points  definitely  to  the  same  conclusion.  The  blad- 
der was  firmly  contracted  and  in  distensible ;  its  retaining  capacity 
did  not  exceed  half  an  ounce.  The  muscular  wall  was  over  half 
an  inch  thick ;  the  mucous  membrane  was  entirely  destroyed  by  the 
inflammation. 

Purulent  Cystitis;  Recovery  after  Two  Years'  Treatment. — This 
patient  was  a  lady  possessing  a  remarkably  good  organization.  She 
was  married,  and  had  one  child.  Her  age  was  thirty  when  her  illness 
began.  While  riding  horseback  she  was  thrown  off,  and  sustained 
some  apparently  slight  injuries.  Her  health  up  to  this  time  had  been 
very  good,  but  from  the  time  of  her  accident — September,  1878 — she 
had  symptoms  of  cystitis.  She  was  residing  in  the  far  West  at  the 
time  of  the  accident,  and,  as  1  did  not  see  her  for  several  years  after, 
and  have  not  been  able  to  correspond  with  the  surgeon  who  then  at- 
tended her,  I  do  not  know  the  relation  which  the  injury  sustained  at 
that  time  bears  to  the  development  of  the  cystitis.  I  only  know  that 
the  one  followed  the  other  immediately.  The  cystitis  persisted,  and 
the  constitutional  symptoms  increased  from  time  to  time.  She  then 
returned  from  the  West  to  New  England  to  be  under  the  care  of  her 
father,  who  is  a  physician  of  known  ability  and  large  experience. 
He  gave  her  every  attention,  and  placed  her  in  the  care  of  a  neigh- 
boring physician,  who  has  a  high  reputation  as  a  gynecologist.  With- 
out giving  full  details  of  her  treatment  at  that  time,  I  may  fairly 
state,  upon  information  received  from  her  father  and  her  physician, 
that  all  the  recognized  ,means  of  treatment  were  tried,  including 
complete  dilatation  of  the  urethra  on  two  occasions.  The  cystitis 
was  not  at  all  relieved  by  the  treatment,  and  the  constitutional  symp- 
toms increased  continuously,  until  she  became  confined  to  bed.  Hav- 
ing a  highly  sensitive  nervous  system,  she  suliei'ed  greatly  from  want 
of  sleep  and  the  constant  pain  of  cystic  tenesmus.  I  first  saw  her 
in  consultation  about  a  year  from  the  time  when  she  was  first  taken 
ill.  It  was  then  that  this  much  of  her  history  was  obtained.  She 
continued  under  treatment  for  six  months  longer,  and,  at  the  end  of 
that  time,  she  consulted  one  of  the  best  known  and  most  worthy 
authorities  in  New  York.     He  advised  cystotomy  and  drainage  for 

49 


754  DISEASES   OF   WOMEN. 

six  months  or  longer,  stating  at  the  same  time  tliat,  in  view  of  tlie 
failure  of  her  former  treatment  to  give  relief,  there  was  nothing  else 
left  to  be  done.  She  declined  to  submit  to  the  operation  at  that 
time.  Her  father  sent  her  to  me  about  two  and  a  half  years  later. 
At  that  time  she  was  obliged  to  urinate  about  every  hour,  night 
and  day.  She  suffered  from  constant  tenesmus,  and  her  nervous 
system  was  greatly  debilitated.  Dr.  McCorkle  examined  the  urine 
for  me,  and  found  that  it  contained  a  large  quantity  of  pus,  and 
that  there  was  a  remarkable  absence  of  epithelial  cells.  The  doctor's 
report  was  that  the  specimen  was  pus,  containing  a  small  quantity 
of  urine,  and  evidently  came  from  a  bladder  which  had  entirely  lost 
the  upper  layer  of  its  mucous  membrane.  The  diagnosis  then  made 
was  chronic  purulent  cystitis.  It  appeared  to  me  that  the  case  was 
one  which  called  for  cystotomy ;  but,  knowing  the  objection  of  the 
patient  to  that  operation,  treatment  was  undertaken,  and  the  results 
soon  gave  some  slight  encouragement.  The  constitutional  treatment 
was  at  tirst  chiefly  tonic  in  character,  and  subsequently  she  took  sahne 
waters,  litliia  waters,  bromide  of  litliia,  and,  finally,  buchu,  benzoin, 
tar,  turpentine,  and  the  like.  These  last  preparations,  however,  did 
not  help  her,  and  were  not  long  continued.  The  local  treatment 
was  at  first  instillations  of  a  warm  solution  of  borax.  Half  an  ounce 
was  instilled  at  a  time,  and  repeated  until  from  eight  to  twelve 
ounces  were  used  at  each  treatment.  The  instillations  were  always 
made  with  very  low  pressure.  As  the  sensitiveness  of  the  parts 
diminished,  the  quantity  used  was  increased  up  to  one  ounce,  but 
never  beyond  that.  Three  months  of  this  treatment  showed  im- 
provement. There  was  less  pain,  and  the  patient's  general  health 
had  improved  considerably.  About  this  time  nitrate  of  silver  was 
used,  and,  later,  sulphate  of  zinc  in  solution  of  various  degrees  of 
strength,  but  this  always  caused  pain.  Indeed,  the  suffering  caused 
by  this  kind  of  treatment  was  great,  and  the  benefit  which  followed 
being  very  little,  it  was  given  up.  I  then  began  to  use  instillations 
of  an  infusion  of  hydrastis  Canadensis,  containing  a  small  quantity 
of  salicylate  of  soda,  which  was  used  to  prevent  decomposition  of 
the  infusion.  I  am  now  satisfied  that  the  salicylate  was  of  value  in 
its  effect  u]:)on  the  suppurating  mucous  membrane.  The  hydrastis 
was  very  faithfully  used,  first  by  myself,  and  subsequently  by  the 
jjatient,  who  made  the  instillations  with  unusual  intelligence  and 
care.  The  result  was  a  gradual  diminution  of  the  pain  and  lessening 
of  the  frequency  of  urination.  The  pus  diminished  in  quantity,  and 
simultaneously  young  epithelial  cells  appeared  in  the  urine,  and  in- 
creased in  number  as  the  pus  diminished.     At  the  end  of  one  year 


ORGANIC  DISEASES   OF  THE   BLADDER.  755 

of  treatment  the  local  and  constitutional  symptoms  had  all  disap- 
peared. The  urine  was  normal,  and  the  patient  had  fully  recovered, 
excepting  that  she  was  obliged  to  urinate  about  every  four  hours. 
This  was  owing  to  contraction  of  the  bladder.  To  overcome  this, 
gradual  distention  was  practiced.  The  patient  was  directed  to  re- 
tain her  urine  until  discomfort,  not  pain,  was  felt.  Injections  were 
used,  each  time  distending  the  bladder  a  trifle  more,  always  stopping 
short  of  causing  pain.  About  two  years  from  the  time  she  first 
came  under  my  care  she  was  perfectly  cured  of  the  cystitis,  and  had 
regained  her  normal  retaining  power.  Four  more  years  have  passed, 
and  there  is  not  the  slightest  evidence  of  any  return  of  the  former 
aifection. 

Cystitis  treated  by  Cystotomy  without  Benefit. — This  lady,  tliirty- 
fom*  years  of  age,  is  married,  and  had  four  children.  She  is  said  to 
have  had  retroversion  of  the  uterus,  which  was  held  in  its  abnormal 
position  by  adhesions.  She  was  treated  for  this  displacement  in  the 
Woman's  Hospital  of  New  York,  so  she  said,  and,  while  under  treat- 
ment, a  cystitis  was  developed,  which  continued  until  I  saw  her. 
After  leaving  the  hospital,  she  became  pregnant,  and  her  sufferings 
increased.  Two  years  ago,  when  her  last  child  was  four  weeks  old, 
she  consulted  a  physician  here  in  Brooklyn,  who  advised  cystotomy, 
and  soon  after  he  performed  the  operation,  using  the  cautery.  She 
experienced  some  relief  from  the  operation,  but  she  still  suffered 
very  acutely.  Being  led  to  hope  that  in  time  the  operation  would 
cure  her,  she  bore  her  afflictions  for  nearly  a  year,  when  she  con- 
sulted me  on  the  5th  of  September,  1881.  I  then  found  her  to  have 
the  tubercular  diathesis,  rather  well  marked,  but  there  was  no  appar- 
ent disease  of  the  lungs  at  that  time.  The  vesico-vaginal  fistula 
made  by  the  operation  was  large  enough  to  admit  the  little  finger, 
and  the  drainage  of  the  bladder  was  quite  complete.  Yet,  strange 
to  say,  she  had  constant  pain  in  the  bladder,  and  a  desire  to  urinate. 
These  symptoms  I  found  to  be  due  to  inflammation  and  ulceration 
of  the  urethra  and  bladder  below  the  fistula.  The  disease  at  this 
location  caused  pain  and  irritation,  which  provoked  reflex  action, 
such  as  that  which  arises  from  the  presence  of  urine  in  the  bladder, 
but  in  a  much  greater  degree.  General  tonic  treatment  was  advised, 
and  local  treatment  employed  to  relieve  the  inflammation  of  the 
urethra  and  neck  of  the  bladder.  Locally,  she  improved  slowly. 
The  pain  and  vesical  tenesmus  subsided  almost  wholly,  but  she  has 
not  yet  recovered  completely.  My  object  was  to  cure  the  local  dis- 
ease, and  then  close  the  fistula.  This  I  shall  never  be  able  to  do. 
While  the  local  disease  is  improving,  she  is  developing  phthisis  pul- 


756  DISEASES   OF   WOMEN. 

inoiialis,  which  precludes  all  thought  of  operating  to  close  the  fistula. 
The  facts  in  this  history,  which  I  trust  will  be  borne  in  mind,  are, 
that  this  patient  was  of  a  tubercular  organization ;  that  cvstotoniy 
did  not  cure  her  cystitis  and  urethritis,  nor  relieve  her  suffering  to 
any  marked  extent. 

Cystotomy  for  the  Cure  of  Cystitis  without  Benefit ;  Death  from 
Phthisis  following  Pneumonia  contracted  while  under  Treatment— Six 
years  ago  I  had  a  case  of  cystitis  under  observation,  which  illustrates 
the  same  facts  in  pathology  and  therapeutics  as  in  the  case  just  re- 
lated. 

I  shall  give  a  very  brief  outline  of  the  history  simply  to  show  the 
result  obtained  by  another  method  of  doing  the  same  operation. 
This  patient  was  a  married  woman,  who  had  several  cliildren.  She 
was  of  a  highly  nervous  temperament,  and  came  from  a  tubercular 
family.  She  consulted  me  for  cystitis,  the  cause  of  which  is  not 
recorded  in  her  history.  I  treated  her  with  injections  for  several 
months  without  benefit.  I  also  dilated  her  urethra,  with  the  same 
result.  In  fact,  I  believe  she  rather  grew  worse,  in  place  of  better, 
while  under  my  care.  Her  general  health  failed  noticeably  at  any 
rate,  and  she  gave  signs  of  a  tubercular  deposit  going  on  in  her 
lungs.  Her  friends  urged  her  to  enter  the  Woman's  Hospital  in 
New  York.  She  did  so,  and  was  under  the  care  of  Dr.  Emmet, 
who  performed  cystotomy,  which  he  did  by  incision  and  keeping 
the  fistula  open,  first  by  his  glass  tube,  and  afterward  by  dilatation 
with  the  finger.  After  the  operation,  she  had  an  attack  of  pneu- 
monia— at  least,  she  told  me  this  when  she  returned  from  hospital. 
Upon  her  return  home,  I  found  that  she  had  been  much  relieved  of 
her  most  urgent  symptoms  by  the  operation.  Still,  there  was  cys- 
titis remaining,  and  she  had  vesical  pain  and  tenesmus.  The  tuber- 
cular disease  of  the  lungs  had  progressed  rapidly,  and  that  portion 
of  her  lung  which  was  involved  in  the  pneumonia  never  cleared 
up.  Her  strength  rapidly  failed,  and  she  died  before  the  cystitis 
subsided. 

CROUPOUS  AND  DIPHTHERITIC   CYSTITIS. 

Croupous  and  diphtheritic  diseases  of  the  bladder  are  very  rare, 
and  therefore  require  but  a  brief  notice  here.  From  the  difficulties 
that  have  existed  in  the  detection  of  the  exact  pathological  conditions 
in  diseases  of  the  bladder,  we  may  presume  that  mild  attacks  of  these 
affections  have  been  overlooked  or  not  correctly  diagnosticated.  But, 
even  granting  this,  we  are  compelled,  from  the  few  recorded  cases, 
to  believe  that  croup  and  diphtheria  of  the  bladder  seldom  occur. 


OEGANIO   DISEASES   OF   THE   BLADDER.  75T 

What  little  exact  knowledge  we  possess  on  this  siil)ject  has  been 
obtained  to  a  great  extent  froni  post-mortem  examinations,  and 
from  this  statement  it  will  be  inferred  and  correctly  too,  that  these 
diseases,  especially  diphtheria,  tend  to  end  fatally. 

From  the  names  employed  one  would  naturally  suppose  that 
these  affections  were  exactly  the  same  as  the  diseases  of  the  mucous 
membrane  of  the  air-passages,  known  as  croup  and  diphtheria.  Be 
that  as  it  may,  it  will  suffice  for  my  present  purpose  to  have  it  un- 
derstood that  in  these  diseases  of  the  bladder  there  is  developed  an 
exudation  or  membrane  like  of  that  of  croup  or  diphtheria. 

The  pathology  of  the  local  lesion  in  these  two  diseases  differs 
only  in  the  depth  of  tissue  involved  and  in  the  character  of  the 
membranous  fonnation.  Thus  in  croupous  cystitis,  the  false  mem- 
brane, while  moderately  adherent,  is  usually  on  the  surface,  covers 
the  whole  or  most  of  the  mucous  membrane  of  the  bladder,  and 
sometimes  portions  of  the  outer  genitals,  and  is  fibro-epithelial  in 
structure. 

The  diphtheritic  membrane,  on  the  contrary,  dips  deeply  into 
the  mucous  membrane  of  the  bladder,  exists  usually  in  scattered 
patches,  and  is  denser  and  more  fibrous  in  character,  its  interstices 
being  filled  with  little  rounded  cells  and  some  fatty  and  granular 
matter. 

Exfoliation  of  the  affected  portions  of  the  vesical  mucous  mem- 
brane usually  results  from  this  diphtheritic  inflammation,  as  in  the 
analogous  affection  in  the  throat.  When  the  membrane  comes 
away,  ulcers  of  varying  size  and  depth  are  left  to  mark  its  former 
site.  The  destructive  processes  are  not  alone  confined  to  the  mu- 
cous and  submucous  tissues,  but  in  some  cases  involve  the  muscular 
coat  of  the  organ.  The  whole  vesical  surface,  not  covered  with  the 
membranous  exudate,  is  of  a  deep-red  color,  and  in  some  places 
ecchymotic,  especially  about  the  exudation.  The  inflammation  is 
truly  acute,  and  passes  rapidly  from  the  stage  of  mucous  exudation 
to  that  of  epithelial  exfoliation  and  pus  formation. 

SymjptoTnatology . — The  symptoms  in  no  way  differ  from  those  of 
acute  cystitis,  save  tliat  as  a  rule  they  are  more  intense  and  the  con- 
stitutional symptoms  are  more  severe.  The  nervous  system  is  usu- 
ally profoundly  affected.  There  is  pain  before,  during,  and  after 
micturition — pain  that  may  be  purely  local,  felt  in  the  outer  genitals, 
or  radiate  in  all  directions. 

When  the  shreds  of  broken-down  membrane  separate,  they  may 
block  up  the  urethra,  and  cause  retention  and  decomposition  of 
urine.     Retention,  however,  may  be  produced  at  any  time  by  in- 


758  DISEASES   OF   WOMEN. 

tense  inflammatory  tumefaction  of  the  urethra,  which  is  often  in- 
volved. 

Tliis  exfoHation  of  false  membrane  must  not  be  conf(junded 
with  the  sloughing  of  the  mucous  membrane  of  the  bladder  caused 
by  pressure  from  overdistention  or  very  severe  inflammation. 

As  the  symptomatology  of  these  diseases  is  very  much  the  same 
as  those  of  acute  and  chronic  cystitis,  it  may  be  best  not  to  enlarge 
upon  them  here,  as  that  would  involve  much  useless  repetition. 

Diagnosis. — Microscopical  examination  of  the  urine,  but  more 
especially  of  the  tissue  shreds,  will  afford  much  reliable  information. 
When  a  membrane  is  found  consisting  of  librillae  interspersed  with 
numerous  small  nucleated  cells,  ha\Tng  undei'gone  fatty  degenera- 
tion, and  involving  the  superficial  mucous  or  muscular  layer,  the  case 
may  be  set  down  as  one  of  diphtheritic  cystitis.  The  urine  rarely 
affords  any  positive  information  ;  and  really  it  is  useless  to  attempt 
to  make  a  differential  diagnosis  between  these  diseases  and  ordinary 
cystitis  in  which  there  is  much  destruction  of  tissue. 

Thus  far  I  have  had  no  opportunity  of  examining  croupous  or 
diphtheritic  disease  of  the  bladder  with  the  endoscope,  and  can  not 
say  how  much  information  could  be  obtained  in  this  way.  I  pre- 
sume that  much  could  be  gained  by  this  instrument,  and  I  base  this 
opinion  upon  the  examination  of  several  cases  of  catarrhal  and 
croupous  inflammation  of  the  rectum.  In  these  cases  the  distinction 
between  catarrh  and  croup  could  be  easily  and  positively  made  by 
the  endoscopic  appearances,  and  I  believe  that  what  has  been  done 
in  determining  rectal  disease  could  be  accomplished  in  diseases  of 
the  bladder. 

In  these  cases  the  vesical  walls  are  very  fragile,  and  this  should 
be  borne  in  mind  in  using  either  catheter  or  endoscope.  This  con- 
dition would  preclude  the  distention  of  the  bladder  with  air  and 
examination  with  Rutenberg's  apparatus. 

Prognosis. — This  is  very  grave  indeed. 

Treatment. — This,  in  brief,  is  to  keep  the  patient  perfectly  quiet, 
to  let  the  diet  be  the  most  sustaining,  the  drinks  free  and  bland,  and 
to  keep  the  bladder  pretty  well  emptied,  to  allay  the  pain  and  spasm 
by  the  judicious  exhibition  of  narcotics,  preferably  by  the  vagina,  in 
suppository.  The  bladder  should  be  washed  out  daily  with  warm 
water,  containing  a  little  of  Labarraque's  solution  or  a  little  carbolic 
acid.  Much  relief  of  both  pain  and  spasm  will  thus  be  afforded,  even 
when  the  inflammation  is  at  its  highest. 

Tissue  shreds  should  be  removed  as  soon  as  their  presence  is  as- 
certained. 


ORGANIC   DISEASES   OF   THE    BLADDER.  759 


CYSTITIS   WITH   EPIDERMOID   CONCRETIONS. 

This  is  a  very  rare  affection  of  the  bladder,  and  I  only  mention 
it  as  a  pathological  cunosity.  Rokitansky  supposes  it  to  be  due  to, 
or  a  sequence  of,  chronic  cystitis.  It  consists  in  an  unusually  rapid 
formation  of  epithelium  by  the  vesical  mucous  membrane,  resulting 
in  the  shedding  of  quite  large  white,  shining  plates  or  bodies  of  this 
caked  scale.  The  following  case,  related  by  Lowenson  (1802),  is 
thus  given  by  Winckel.  The  patient  spoken  of  by  him,  suffered 
from  mitral  stenosis,  and  came  into  hospital  in  a  morilmnd  condition. 
After  death  her  bladder  was  found  to  be  enormously  dilated.  From 
it  were  taken  a  great  number  of  small,  rounded  yellow  masses,  lying 
between  a  number  of  plates  of  dullish  color,  the  general  appearance 
being  that  of  yellow  pea-soup,  with  some  of  the  hulls  left  in.  The 
whole  of  the  internal  surface  of  the  bladder  was  covered  with  flakes, 
many  of  them  having  these  little  balls  interposed  and  superimposed. 
Their  diameter  varied  from  one  twenty-fifth  to  one  half  inch.  These 
attached  flakes  were  tolerably  firm  and  bright,  something  like  mother- 
of-pearl.  From  the  mucous  membrane  itself,  after  removal  of  these 
flakes,  pieces  of  membrane  could  be  stripped  off.  Except  in  these 
places  the  mucous  membrane  seemed  normal.  The  urethra  and 
ureters  were  normal,  but  the  kidneys  were  in  a  condition  of  granu- 
lar atrophy. 

On  microscopic  examination  it  was  found  that  the  young,  often- 
times fatty  degenerated  epithelial  cells  (in  the  commencement),  as 
they  approached  the  surface,  took  on  gradually  all  the  changes  of 
the  very  large  epidermic  cell,  becoming  non-nucleated  and  granular. 
The  little  balls  consisted  of  grains  of  fat,  calciform  concretions,  lit- 
tle nuclei,  and  epidermic  cells.  There  was  considerable  stearine  but 
no  cholesterine.  Reich  claims  lately,  however,  to  have  found  the 
latter  in  the  vesical  mucous  membrane  of  a  man  fifty-six  years  old, 
who  suffered  from  catarrh  of  the  bladder. 

Treatment. — Of  course  I  have  no  experience,  never  having  seen 
a  case,  but  on  general  principles  I  would  suggest  that  the  treatment 
would  be  to  relieve  any  inflammation  or  irritation  that  may  be  pres- 
ent, the  exhibition  of  alkalies  and  arsenic  (in  small  doses)  by  the 
mouth,  daily  washing  out  of  the  bladder,  removing  all  scales  or 
plates  that  form,  and  the  application  of  a  strong  alkaline  solution  to 
the  diseased  surface. 

I  am  unable  to  give  the  symptoms  of  this  disease.  The  same  may 
be  said  of  the  diagnosis.  I  presume,  however,  that  an  examination 
of  the  urine  would  enable  one  to  determine  the  nature  of  the  trouble. 


CHAPTER   XLII. 

NON-INFLAMMATORY   DISEASES   OF    THE    BLADDER. 

DISLOCATION  OF  THE  BLADDER. 

II.  Non-inflammatryry  diseases  of  the  Madder.     These  are  : 

1.  Dislocations. 

2.  Foreign  bodies. 

3.  Rupture. 

1.  Dislocations. — -These  may  be  of  six  kinds :  {a)  upward  ;  (5) 
backward ;  (c)  forward ;  {d)  lateral ;  {e)  downward ;  in  addition  to 
these,  we  may  have  (/")  inversion  of  the  bladder. 

Some  of  these  are,  even  in  their  worst  form,  not  tnie  disloca- 
tions, but  represent  some  hindrance  to  the  proper  distention  of  the 
organ  or  its  position  when  distended.  Of  all  dislocations,  the  most 
important  are  the  upward,  backward,  and  downward.  All  of  them, 
however,  interfere  more  or  less  with  the  vesical  function.  Marked 
dislocation  of  a  healthy  bladder  often  gives  rise  to  less  disturbance 
than  slio-ht  dislocation  of  an  alreadv  irritable  orojan. 

Dislocations  of  the  bladder  have  various  causes,  the  most  com- 
mon and  troublesome  being  abnormalities  of  structure  and  position 
of  the  uteiTis  and  vagina. 

As  a  matter  of  fact,  these  dislocations  are  usually  secondary  to 
some  affection  of  the  other  pelvic  organs.  This  necessitates  a  de- 
scription of  their  causes  as  well  as  the  conditions  under  which  they 
occur,  thus  deviating  from  the  general  order  followed  in  this  work. 

(«)  Dislocation  Upward. — The  upward  dislocation  of  the  bladder 
may  be  caused  by  the  dragging  up  of  the  organ  by  the  gradual  rising 
from  the  pelvis  of  the  gravid  uterus.  This,  however,  is  a  rare  affec- 
tion, and  only  occurs,  I  think,  in  cases  where  there  has  been  previous 
inflammatory  action  in  the  pelvis,  gluing  the  parts  together.  In 
most  pregnancies  the  bladder  retains  what  is,  under  the  circum- 
stances, its  normal  position.     Bands  of  adhesion  passing  from  the 


NON-INFLAMMATORY   DISEASES   OF   THE    BLADDEPv.       Y61 

bladder  to  the  various  aljdominal  and  pelvic  viscera  may,  when  sliort- 
ening  takes  place,  produce  this  dislocation.  It  may  also  be  produced 
by  ovarian  tumors,  and,  in  some  cases  of  uterine  retroflexion  and 
retroversion.  The  dislocation  accompanying  the  last  two  affections 
is,  however,  usually  more  backward  than  upward. 

The  other  most  probable  causes  are  tumors  about  the  neck  or 
base  of  the  organ,  tumors  of  the  cervix  uteri,  pelvic  deformities,  and 
pelvic  exostoses. 

The  symptoms  are  usually  those  of  irritable  bladder.  In  some 
cases  of  pelvic  tumor  the  pressure  on  the  neck  of  the  bladder,  forc- 
ing it  against  the  pubes,  produces  ^retention.  This  is  purely  me- 
chanical. In  other  cases,  where  there  is  no  obstruction  to  the  out- 
flow, but  pressure  on  the  bladder,  there  may  be  incontinence ;  and, 
again,  from  traction  on  the  muscular  walls,  patients  are  unable  to 
contract  and  ex23el  the  vesical  contents,  and  retention  results. 

I  saw  a  case,  in  consultation  with  Dr.  A.  W.  Ford,  of  Brooklyn, 
in  which  the  patient  had  retention  of  urine,  so  that  she  could  not 
m^inate  while  standing,  but  was  compelled  to  lie  down  before  the 
bladder  could  be  emptied.  The  retention  lasted  one  week,  and  was 
brought  on  by  the  efforts  to  urinate,  which  wedged  the  uterus  in  the 
pelvis,  and  compressed  the  neck  of  the  bladder.  She  was  relieved 
by  urinating  while  on  the  hands  and  knees. 

(b)  Dislocation  Backward. — This  dislocation  stands  next  in  order 
of  importance  and  unfavorable  results  to  downward  dislocation.  It 
may  be  caused  by  tumors  of  the  abdomen  or  by  pehdc  adhesions,  but 
the  most  frequent  cause  is  backward  dislocation  of  the  uteinis,  such 
as  retroflexion  and  retroversion.  Retroversion  affects  the  bladder 
in  the  same  manner  as  prolapsus,  except  when  the  uterus  is  very 
much  enlarged,  and  is  throAvn  backward  and  impacted  in  the  pelvis, 
so  that  the  cervix  presses  firmly  on  the  urethra.  In  such  cases  urina- 
tion is  impossible.  Examples  of  this  are  seen  in  retroversion,  occur- 
ring in  the  early  months  of  pregnancy  or  after  delivery.  Schatz  gives 
a  case  due  to  retroflexion  of  the  uterus  during  pregnancy,  produc- 
ing the  same  trouble  in  the  bladder  as  retroversion. 

Winckel  saw  a  case  in  the  body  of  a  non-puerperal  woman,  in 
which  the  uterus  was  lying  almost  horizontally  in  the  pelvis,  with 
its  fundus  adherent  to  the  rectum.  That  part  of  the  bladder  that 
was  drawn  most  backward  had  a  diverticulum,  containing  a  calcu- 
lus. The  neck  of  the  bladder  was  fastened  dow^n  posteriorly  by 
tight  bands  of  adhesion  that  passed  from  it  over  the  nterus  to  the 
rectum. 

In  retro-displacements  of  the  bladder,  with  no  pressure  on  the 


762 


DISEASES   OF    WOMEN. 


vesical  neck,  tlie  symptoms  are  usually  those  of  irritation,  causing 
frequent  urination  and  tenesmus. 
I  give  here  tlie  following  cases 


Fig. 


234.  —  Retroversion  of  the  gravid  uterus 
(after  Schatz).  The  bladder  pulled  upwr.rd 
and  backward,  and  the  urethra,  u,  put  great- 
ly upon  the  stretch. 


as  they  are  of  interest,  and 
may  serve  to  fix  more  clear- 
ly in  the  mind  the  general 
points. 


ILLUSTRATIVE    CASES. 

The  first  is  a  case  of 
chronic  retroversion  of  the 
uterus,  causing  marked  vesi- 
cal trouble  in  a  nervous  wom- 
an. The  cause  of  the  blad- 
der trouble  is  here  double : 
first,  vesical  neurosis,  and 
second,  a  displaced  uterus. 

Mrs.  H.,  aged  thirty-six. 
Marned  five  years,  and  a 
widow  three  years,  of  a  marked  nervous  temperament.  Has  never 
been  pregnant.  Menstruation  always  normal,  and  general  health  fair 
in  early  life.  Her  general  system  has  been  much  reduced  by  nursing 
her  husband,  who  died  of  phthisis.  Nervous  system  also  much  im- 
paired. When  first  seen,  all  the  functions  except  those  of  the  blad- 
der were  performed  well.  She  suffered  night  and  day  from  frequent 
urination,  but  there  was  no  pain  either  during  or  after  the  act,  unless 
she  tried  to  hold  her  water  for  a  few  hours,  when  there  was  great  pain 
after  the  completion  of  evacuation.  Nervous  excitement,  pleasant 
or  unpleasant,  made  the  trouble  much  worse.  Her  urine  was  normal. 
On  examination,  complete  retroversion  of  the  uterus  was  found, 
with  shortening  of  the  anterior  vaginal  wall ;  the  bladder  was  much 
contracted,  but  otherwise  normal.  The  uterus  was  restored  to  its 
place,  and  held  there  by  a  pessary.  Hydrobromic  acid  in  thirty-min- 
im doses  was  given  four  times  a  day.     She  made  a  rapid  recovery. 

The  next  is  a  case  of  vesical  tenesmus  and  partial  retention  from 
a  sudden  retroversion  of  the  uterus. 

Mrs.  G.,  aged  forty-three,  the  mother  of  four  children.  Widow 
for  several  years.  She  was  a  strong,  healthy  lady,  and  had  been  on 
her  feet  all  day  attending  to  her  household  duties,  and  in  the  even- 
ing, while  hanging  some  pictures,  slipped  from  a  chair,  and  fell 
heavily  to  the  flooi",  striking  on  her  feet.  She  was  at  once  seized 
with  a  desire  to  urinate,  and  soon  after  pelvic  tenesmus  came  on. 
The   desire  to   urinate   was   constant,  and,  after  strong  expulsive 


NON-INFLAMMATORY  DISEASES  OF  THE   BLADDER.        763 

efforts,  she  was  able  to  pass  a  little  urine  from  time  to  time,  but 
without  rehef.  The  bowels  became  distended  and  tympanitic.  On 
the  following  day  she  was  ordered  anodynes,  but  they  gave  very 
little  relief. 

On  the  next  day  she  was  examined,  and  the  uterus  was  found  to 
be  completely  retroverted,  and  the  bladder  full,  but  not  overdis- 
teuded.  Replacing  the  uterus  gave  her  great  relief  at  once,  and  she 
has  remained  well  and  free  from  all  bladder  trouble  since  the  acci- 
dent occurred,  some  two  years  ago.  This  was  a  case  of  acute  retro- 
version of  the  uterus,  producing  an  intensely  painful  affection  in  a 
normal  bladder. 

(c)  Dislocation  Forward. — Forward  dislocation  of  the  bladder, 
unless  it  be  througli  the  open  abdominal  walls,  is  very  rare.  Some 
change  in  its  shape  from  pressure  of  organs  or  tumors  from  behind 
may  occur,  but  this  is  really  not  a  true  displacement,  except  in  some 
rare  and  marked  cases.  The  most  frequent  cause  is  pressure  from 
the  anteverted  and  enlarged  uterus  in  either  the  virgin  or  puerperal 
state.  Anteversion  of  the  uterus  usually  causes  frequent  urination, 
perhaps  as  much  so  as  prolapsus ;  but  whether  this  frequency  is  due 
to  the  fundus  uteri  resting  on  the  bladder,  or  to  the  supersensitive- 
ness  of  the  whole  pelvic  organs,  which  usually  accompanies  this  dis- 
location, I  have  not  always  been  able  to  determine.  I  have  been  in- 
clined to  the  belief  that  the  latter  was  the  case.  In  this  displace- 
ment (anteversion)  the  uterus  is  generally  enlarged  and  elevated,  so 
that  the  body  and  fundus  rest  upon  the  bladder,  and  imj)ede  its  dis- 
tention. 

True  dislocation  of  the  bladder  forward  is  the  rarest  of  all  dis- 
locations, only  three  cases  being  on  record.  It  has  been  variously 
called  ectopia  of  the  unfissured  bladder,  ectopia  vesicae  totalis,  and 
prolapsus  vesicae  completus  per  fissuram  tegumentorum  abdominis. 
The  first  name  is  too  vague,  the  last  best  of  all,  but  rather  lengthy 
for  every-day  use. 

The  three  cases  on  record  are  by  G.  Yrolik,  Stoll,  and  Lichten- 
heim.  In  all  these  the  bladder  was  protruded  througli  a  small  slit 
in  the  abdominal  wall,  and  appeared  as  a  bright-red,  rounded  tumor 
at  the  lower  and  anterior  part  of  the  abdomen.  In  Lichteuheim's 
case  only  was  the  tumor  reducible.  The  pubic  bones  were  separated 
about  two  inches.  The  urine  could  be  retained  perfectly,  and  the 
patient  was  able  to  micturate  in  a  small  stream.  Microscopical  ex- 
amination of  the  outer  covering  of  the  bladder-walls  proved  it  to  be 
mucous  membrane,  hke  that  lining  the  interior  of  the  organ. 

In  G.  Yrolik's  case,  according  to  Winckel,  there  is  doubt  as  to 


7Gi  DISEASES   OF   WOMEN. 

whether  it  was  a  true  vesical  ectopia.  He  believes  it  to  have  been 
a  gaping  of  the  fissured  abdominal  walls  over  a  diluted  uraeluis,  the 
latter  communicating  with  the  bladder  by  a  small  opening. 

In  Lichtenheim's  patient  no  operative  measures  were  thought  of, 
for,  beyond  a  little  excessive  secretion  of  the  external  surface,  no 
trouble  was  experienced.  If,  however,  from  the  protrusion  of  the 
tumor  or  other  cause,  difficulty  in  passing  or  retaining  urine  be  pres- 
ent, an  attempt  should  be  made  to  close  the  abdominal  fissure.  If 
it  be  large,  two  or  more  fla]5s  may  be  needed  to  accomplish  the  de- 
sired result.  The  operation  is  very  like  that  for  fissure,  already  de- 
scribed, only  more  simple. 

If  an  operation  is  not  desired  or  consented  to,  the  patient  should 
wear  a  concave  compress,  and,  by  attention  to  bandaging,  keep  the 
surface  of  the  organ  in  as  nearly  a  normal  condition  as  possible. 

{d)  Lateral  Displacements. — Lateral  displacement  of  the  bladder 
is  not  very  often  met  with.  It  is  generally  due  to  inguinal  or  fem- 
oral hernia,  tumors  at  the  side  and  base  of  the  organ,  and  contract- 
ing pelvic  adhesions.  There  is  generally  more  or  less  distortion  of 
the  urethra  that  may  hinder  the  outflow  of  urine  or  prevent  the  easy 
introduction  of  a  catheter.  Irritability  may  result,  but  it  is  not  so 
common  as  in  the  other  varieties,  the  organ  being  generally  but 
slightly  displaced,  and,  soon  getting  used  to  the  disturbing  cause 
arising  from  the  malposition,  produces  but  little  disturbance. 

One  case  of  this  kind  I  have  seen  which  was  of  interest.  The 
patient  was  a  young  lady,  who  had  had  a  pelvic  peritonitis,  which 
left  her  with  pelvic  tenesmus,  ovarian  pain,  and  some  vesical  tenes- 
mus and  difficulty  in  emptying  the  1)ladder.  One  of  my  assistants, 
while  examining  her,  found  a  fluctuating  tumor  on  the  left  side, 
which  he  supposed  to  be  an  ovarian  cyst,  but  which  proved  to  be 
a  left  lateral  displacement  of  the  bladder  fixed  in  its  malposition  by 
adhesions. 

Causation. — Its  causes  are  of  two  kinds — predisposing  and  excit- 
ing. Of  the  predisposing,  the  most  common  are  a  loose,  fiabl\y  con- 
dition of  the  vesico-vaginal  septum,  excessive  venosity  of  same  (these 
may  be  due  to  pregnancy  or  to  a  general  systemic  condition),  ab- 
normally capacious  vagina,  unusually  large  introitus  vagina?,  total  or 
partial  loss  of  perineal  body,  and  the  tendeuc}'  of  the  bladder  to 
pouch  inferiorly  as  age  advances. 

As  exciting  causes,  we  have  %'iolent  expulsive  efforts,  as  in  def- 
ecation, lifting  heavy  weights,  and  especially  child-bearing.  The 
latter  is  probably  one  of  its  most  common  causes,  for  not  only  do 
we  have  expulsive  efforts  of  the  most  violent  kind,  but  a  lax,  spongy 


NON-INFLAMMATORY  DISEASES   OF  THE  BLADDER.       765 

condition  of  the  vesico- vaginal  septum — i.  e.,  tlic  anterior  vaginal 
and  posterior  vesical  walls,  which  are  pushed  downward  before  the 
advancing  head. 

Another  common  cause  is  prolapsus  uteri,  though  in  many  cases 
the  cystocele  precedes  the  prolapse  of  the  womb.  Whichever  is 
the  cause,  the  one  aggravates  the  other.  In  slight  prolapse  of  the 
uterus,  the  vesical  symptoms  are  only  those  of  irritation ;  and  it  is 
a  strange  fact  that  the  irritation  is  often  as  great  in  the  first  degree 
of  prolapse  as  in  the  third. 

Other  less  frequent  causes  of  cystocele  may  be  tumors  in  the 
posterior  vesical  or  anterior  vaginal  wall,  stone  in  the  bladder,  vesi- 
cal diverticuli,  violent  efforts  at  urination,  and  marked  pressure  from 
above. 

The  bladder  begins  to  sag  inferiorly  as  age  advances,  and  conse- 
quently the  tendency  to  prolapsus  advances,  as  does  the  age.  The 
number  of  pregnancies  may,  however,  have  more  to  do  with  the  fre- 
quency than  the  tendency  to  pouching  in  old  age. 

(e)  Dislocation  Downward. — I  have  reserved  this  malposition  to 
the  last,  because  it  is  the  m.ost  important.  There  are  various  grades 
of  tlie  dislocation,  the  most  marked  of  which  is  known  as  cystocele 
vaginalis. 

Pathology. — This  affection  may  be  conveniently  divided  into 
three  grades.  In  the  first,  there  is  but  a  slight  bagging  of  the  or- 
gan. In  the  second,  about  one  half  the  bladder  lies  below  the  nor- 
mal level  of  the  anterior  vaginal  wall,  giving  the  organ  an  hour- 
glass shape,  the  urethra  entering  the  upper  segment  just  above  the 
point  of  partial  constriction.  In  the  third  or  highest  grade,  the 
whole  bladder  lies  below  the  level  of  the  normal  anterior  vaginal 
wall.  The  urethra  in  these  cases  has  a  direction  from  above  back- 
ward and  downward.  The  ureters  in  the  last  two  grades  are  so  bent 
and  obstructed  by  pressure,  that  dilatation  and  hydronephrosis  may 
result.  Such  instances  are  given  by  Phillips,  Froreiss,  Yirchow, 
Bi'aun,  and  Winckel. 

The  vesico-uterine  pouch  is,  in  cases  of  marked  vesical  and 
uterine  prolapse,  greatly  increased  in  size,  and  may  contain  a  loop  of 
intestine.  In  some  rare  cases  it  may  become  constricted  superiorly, 
and  exist  as  a  closed  sac. 

In  chronic  cases  the  vesical  mucous  membrane  becomes  hyper- 
trophied,  and,  in  the  lower  segment  especially,  congested  and  oedem- 
atous.  To  this  may  be  superadded  cystitis  and  ulceration,  which 
often  follow  in  cases  of  long  standing. 

Symptomatology. — In  the  first  grade  of  downward  dislocation 


766  DISEASES  OF   WOMEN. 

the  symptoms  are  those  of  irritable  bladder,  such  as  frequent  and 
sometimes  painful  urination.  AVhen  tlie  displacement  has  existed 
for  a  considerable  time,  the  bladder  seems  to  accommodate  itself  to 
the  new  relations,  and  the  calls  to  urinate  become  less  frequent.  In 
cases  in  which  the  prolapsus  of  the  bladder  is  slight  and  there  is  dila- 
tation or  prolapsus  of  the  upper  third  of  the  urethra,  partial  inconti- 
nence occurs,  a  very  annoying  symptom.  Every  time  the  patient 
coughs,  lifts  a  heavy  weight,  steps  suddenly  down  from  the  curb- 
stone into  the  street,  or  even  indulges  in  a  hearty  laugh,  there  is  a 
sudden  escape  of  urine. 

In  complete  prolapsus  of  the  uterus  and  bladder,  we  find  instead 
of  frequent  urination,  difficult  urination,  and  in  the  worst  cases,  re- 
tention. Partial  retention  always  occurs  in  the  marked  cases,  and 
the  urine  remaining  in  the  bladder  decomposes,  and  in  time  causes 
cystitis,  which  greatly  aggravates  the  patient's  sufferings.  Such 
cases  are  very  like  those  occurring  in  old  men,  and  due  to  retained 
urine  by  reason  of  an  enlarged  prostate  gland. 

There  is  usually  a  dragging  pain  experienced  in  the  region  of 
the  umbilicus,  which  is  due  to  traction  on  the  urachal  cord,  and  also 
a  constant  sense  of  pain  and  uneasiness,  due  partly  to  the  vesical  and 
partly  to  the  uterine  malposition. 

To  fully  empty  the  bladder  in  the  worst  cases,  it  is  necessary  to 
relax  the  parts  by  lying  down,  and  then  force  out  the  urine  by  press- 
ure on  the  vaginal  tumor. 

Cystitis  is  a  common  secondary  affection,  and  is  due  to  decompo- 
sition of  the  retained  urine,  and  to  chronic  congestion  with  oedema 
and  hypertrophy  of  the  mucous  membrane.  Wiuckers  experience 
has,  however,  differed  from  that  of  most  observers,  he  having 
failed  to  find  a  single  instance  of  cystitis  in  sixty-eight  cases  of  cys- 
tocele. 

From  pressure  on  the  ureters  there  may  result  dilatation  and 
hydronephrosis,  and  if  marked  or  long-continued,  urremia.  There 
may  also  be  set  up  that  condition  known  as  pericystitis,  and  the 
lower  vesical  segment  be  rendered  irreducible  owing  to  the  formation 
of  adhesions. 

If  cystocele  occurs  in  a  patient  already  suffering  from  cystitis, 
the  original  trouble  is  of  course  greatly  aggravated. 

Cystocele  may  interfere  with  delivery  during  childbirth.  In 
one  such  case,  McKee,  being  unable  to  push  a  catheter  into  the 
bladder,  punctured  the  tumor  with  a  lancet,  and  delivery  was  rap- 
idly accomplished.  In  another  case,  a  certain  physician  mistook 
the  vesical  tumor  for  the  bag  of  waters,  and  punctured  it. 


I 


NON-INFLAMMATORY  DISEASES  OF  THE  BLADDER,       767 

Diagnosis. — This  is  readily  made.  The  patient  should  he  laid 
upon  her  hack,  with  the  thighs  flexed  on  the  hody.  If  the  tumor  is 
already  down  it  should  be  examined  carefully,  and  also  the  position 
and  condition  of  the  neighboring  organs.  If  possible,  a  catheter 
should  be  passed  into  the  bladder,  to  ascertain  if  it  enters  the  tumor 
and  the  direction  it  takes  in  so  doing  should  be  observed.  The 
tumor  should  be  slightly  compressed,  and  notice  taken  whether  the 
urine  flows  from  it  through  the  catheter.  An  attempt  should  also 
be  made  to  try  to  reduce  it.  The  urine  should  be  carefully  ex- 
amined for  pus,  mucus,  albumen,  epithelial  elements,  and  the  amount 
of  urea  should  be  determined. 

Prognosis. — The  r)rognosis  is  generally  good  ;  but  in  giving  an 
opinion  the  degree  of  dislocation,  the  size  of  the  tumor,  the  condi- 
tion of  its  mucous  membrane,  whether  it  is  reducible  or  not,  the 
age  of  the  patient,  and  the  gravity  of  the  producing  cause,  must  all 
be  taken  into  consideration. 

In  young  patients,  Sims,  Simon,  Hegar,  Yerf,  and  others  claim 
to  have  obtained  radical  cures.  Some  of  these  cures  were  not,  how- 
ever, lasting.  Scanzoni  claimed  that  he  had  never  seen  an  opera- 
tion for  this  displacement  that  resulted  in  a  permanent  success,  and 
that  his  own  operations  were  by  no  means  satisfactory.  My  own 
experience  entirely  accords  with  that  of  Scanzoni. 

Treatment. — The  treatment  consists  in  reposition  and  retention. 
The  former  is  easy,  the  latter  hard  to  accomplish,  as  prolapsus  uteri 
and  cystocele  generally  go  hand  in  hand ;  one  can  not  be  treated 
without  the  other. 

Having  pushed  the  uterus  up  into  position,  emptied  the  bladder 
and  replaced  it,  some  mechanical  ^^-1, 

means  should  be  sought  to  retain  y^^L  ^Ak 

one  or  both  organs  in  place.  raF^i^^^ 

ing  the  prolapsed  bladder  I  de-     m^        ^^^^^|p^      ^"*^^Sb 
vised  the  pessary  shown  in  Fig.     ^t^       "  ^^^^^^^^^^^j^ 
235,  and  it  has   been  found   to      ^i^^gj^^F^ 

accomplish  the  obiect  fairly  well      Fi«-    235.— Pessary   for   prolapsus  of   the 

^               1    •      "!i           •               •  bladder  (bkene).     The  mam  portion,  a, 

when   the    pelvic   floor   is   not  m-  surrounds  the  cervix  uteri,  and  b  sup- 

iured  ports  the  bladder  and  upper  portion  of 

**           '  .                        •Ill  *^^  urethra.     The  other  part,  c  c,  joins 

I  his   pessary   is    adapted    and  the  main  portion  in  front  of  the  uterus, 

introduced    in  the  same  way  as  a  and  rests  on  the  posterior  \yalls  of  the 

''  vagina. 

retroversion  pessary,  an  account 

of  which  will  be  found  under  the  head  of  the  treatment  of  retro- 
version. 


TC8 


DISEASES   OF   WOMEN. 


The  facility  of  introduction  and  removal  is  one  of  the  minor,  but 
bj  no  means  unimportant,  qualities  of  this  pessary. 

Several  sizes  are  made,  wliich  answer  in  most  of  the  forms  of 
displacement  of  the  bladder ;  but  a  case  will  occasionally  occur  in 
which  it  is  necessary  to  first  take  measurements,  and  have  the  in- 


FiG.  236. — ^Pessary  holding  up  the  bladder. 

strument  made  exactly  to  suit.  This  can  be  easily  done.  The  pa- 
tient is  placed  on  her  left  side,  and  after  introducing  the  speculum, 
the  uterus  and  bladder  are  restored  to  their  proper  positions  ;  then 
a  thin  strip  of  sheet  lead  is  bent  to  the  size  and  shape  of  the  ante- 
rior walls  of  the  vagina  and  cervix  uteri.  This  form  will  enable  the 
instrument-maker  to  produce  the  required  size  and  shape  of  the 
pessary.  I  have  also  devised  another  form  which  suits  some  cases. 
It  is  like  the  retroversion  pessary 
which  I  use,  but  the  sides  anteriorly 
are  made  more  curved  and  very 
much  thicker  than  the  ordinary  one, 
Fig.  237. 

Should  a  pessary  fail  to  accom- 
plish the  desired  result  and  the  case 
grow  daily  worse,  the  operation  may 
be  performed  which  was  first  done 


Fig.  237. — Modification  of  the  retrover- 
sion pessary,  used  in  prolapsus  of 
the  bladder. 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER.        769 

by  Joubert,  then  by  Baker  Brown,  and  subsequently  carried  out 
and  improved  by  Sims.  It  consists  in  the  excision  of  an  ellipti- 
cal or  V-shaped  piece  from  the  anterior  vaginal  wall,  and  bring- 
ing the  edges  together  by  sutures.  When  healing  has  taken  place 
the  vagina  is  markedly  narrowed,  and  the  bladder  has  an  improved, 
if  not  a  perfect  floor  to  rest  upon.  This  operation  is  seldom 
called  for,  and  I  believe  that  it  should  be  limited  to  cases  where 
there  is  marked  thickening  of  the  vesical  and  vaginal  walls.  AVhen 
the  operation  has  been  performed,  I  have  found  it  necessary  to  use 
a  pessary,  to  prevent  a  return  of  the  prolapsus.  If  there  be  a  lacer- 
ation of  the  perinseum  this  too  is  to  be  remedied.  In  fact,  the  great 
majority  of  cases  of  prolapsus  of  the  bladder  are  due  to  some  imper- 
fection of  the  pelvic  floor,  and  I  have  therefore  obtained  by  far  the 
best  results  by  restoring  the  pelvic  floor. 

I  have  also  found  that  it  was  better  to  bring  together  as  much 
tissue  as  possible  in  the  posterior  vaginal  wall  and  at  the  vaginal 
outlet. 

In  cases  of  but  slight  downward  dislocation,  and  where,  from  a 
relaxed  condition  of  the  vaginal  wall  and  septum,  vesical  prolapse  is 
to  be  feared,  the  employment  of  a  proper  pessary  will  suffice. 

ILLUSTRATIVE    CASES. 

Frequent  Tlriiiatioii  due  to  Prolapsus  of  the  Bladder. — The  patient 
was  thirty-two  years  old,  and  had  given  birth  to  five  children.  .  She 
had  always  been  well  and  strong,  and  at  the  time  that  I  saw  her  sbe 
was  in  very  good  general  health.  After  her  last  confinement,  one 
year  previous,  she  began  to  suffer  from  frequent  urination.  At  first 
she  obtained  relief  from  emptying  the  bladder,  but  subsequently 
the  desire  to  urinate,  though  not  very  urgent,  was  constant  when  she 
was  upon  her  feet.  On  lying  down  she  obtained  relief  and  retained 
the  urine  all  night,  but  upon  rising  and  going  about  the  tenesmus  re- 
turned. 

By  digital  examination  I  detected  a  prolapsus  of  the  bladder, 
but  only  in  a  slight  degree. 

There  was  considerable  relaxation  of  the  pelvic  floor  and  of  the 
vaginal  walls,  but  no  laceration  of  either.  In  all  other  respects  she 
was  quite  well.  The  urine  was  normal.  She  was  ordered  to  rest 
for  a  few  days,  most  of  the  time  reclining,  and  to  use  vaginal  injec- 
tions night  and  morning  of  sulphate  of  zinc,  sixty  grains  to  the 
quart  of  warm  water.  Afterward  a  pessary  was  used  shaped  like 
Graily  Hewett's  anteversion  pessary,  but  having  the  anterior  bars 
thickened. 
50 


770  DISEASES  OF   WOMEN. 

Immediate  relief  was  given  by  the  pessary,  and  she  was  able  to 
walk  and  stand  as  she  used  to  in  former  times.  Tlie  zinc-douche 
was  kept  up  once  a  day,  and  she  was  cautioned  ao;ainst  walking  or 
standing  too  long.  At  the  end  of  six  weeks  the  pessary  was  re- 
moved to  see  if  she  could  do  without  it.  In  a  few  days  the  old 
symptoms  began  to  return,  and  tlie  pessary  was  replaced  to  her  en- 
tire relief.  From  this  time  onward  the  pessary  was  clianged  once  a 
month  for  a  smaller  one.  Seven  months  afterward  the  instrument 
was  removed,  and  the  injections  of  the  zinc  solution  continued  for 
one  month  longer.     She  had  no  further  trouble. 

Prolapsus  of  the  Bladder  caused  by  Laceration  of  the  Perinaeum. — 
This  lady  was  forty-one  years  old,  of  large  form,  and  had  an  excel- 
lent constitution  ;  she  had  two  daughters,  the  youngest  seven  years  of 
age.  For  nearly  six  years  she  had  suffered  from  vesical  tenesmus  and 
frequent  urination.  These  symptoms  were  greatly  aggravated  by 
the  erect  position.  In  fact,  for  a  long  time  she  was  quite  comfort- 
able while  sitting  or  lying  down,  especially  the  latter.  Her  symp- 
toms gradually  increased,  and  within  the  past  two  years  she  has  had 
partial  incontinence.  Any  sudden  motion  such  as  is  caused  by  cry- 
ing or  sneezing  would  cause  a  spurt  of  urine  which  was  most  dis- 
tressing to  her.  She  became  quite  helpless  although  in  perfect 
health.  Being  unable  to  stand  or  walk  for  any  length  of  time  and 
having  partial  incontinence  she  remained  in  the  house  all  the  time. 
She  had  been  treated  with  all  kinds  of  drugs,  but,  as  might  have 
been  expected,  without  any  relief.  I  found  that  she  had  a  laceration 
of  the  perinseum,  and  also  a  bilateral  laceration  of  the  cervix  uteri. 
The  bladder  was  prolapsed  and  the  upper  third  of  the  urethra  pre- 
sented the  usual  signs  of  the  ordinary  cystocele.  She  was  admitted 
to  my  private  hospital,  and  after  having  been  submitted  to  prepara- 
tory treatment  the  cervix  was  restored.  While  she  was  recovering 
from  that  operation  the  bladder  was  kept  in  place  by  the  tampon, 
and  astringent  vaginal  injections  were  used.  One  month  later  the 
pelvic  floor  was  restored,  and  as  much  tissue  brought  together  as  pos- 
sible. After  the  operation  the  pelvic  floor  was  kept  well  sup- 
ported with  a  compress  and  T-bandage.  The  astringent  injections 
were  continued.  Six  weeks  from  the  last  operation  she  was  per- 
mitted to  take  exercise,  but  the  pelvic  floor  was  supported  for  two 
months  longer.  After  restoring  the  pelvic  floor  it  was  necessary  to 
use  the  catheter  to  draw  the  urine ;  that  excited  some  irritation  of 
the  bladder,  but  this  was  relieved  by  injections  of  borax  and  water. 
She  made  a  perfect  recovery,  and  has  remained  quite  well  for  more 
than  four  years. 


NON-INFLAMMATORY  DISEASES   OF  THE   BLADDER.       771 

Cases  of  Displacement  of  the  Bladder  due  to  Displacement  of  the 
irterus  and  Causing  Retention  of  Urine. — (I).  Berry  Hart,  M.  D.,  "  Ob- 
stet.  Jour.,"  Great  Britain  and  Ireland,  August  3,  1880): 

Case  I. — A.  B.,  aged  eighteen,  was  seen  in  Prof.  Simpson's  out- 
patient clinic,  on  account  of  white  discharge  and  pain  on  making 
water.  Ocular  examination  of  the  external  parts  showed  a  recent 
laceration  of  the  hymen  and  glairy  discharge  from  the  ostium  vaginae. 
On  vaginal  examination  the  cervix  was  found  normal  in  all  respects, 
except  that  the  os  looked  downward  and  forward  ;  bimanually,  a  fluc- 
tuating tumor,  reaching  up  a  little  above  the  level  of  the  pelvic  brim, 
was  felt  in  front  of  the  partially  retroverted  unimpregnated  uterus. 
The  catheter  introduced  drew  off  twenty-seven  ounces  of  urine. 

Case  II. — Mrs.  C.  was  admitted  to  Prof.  Simpson's  ward  on  ac- 
count of  retention  of  urine,  necessitating  catheterism  ;  bimanual  ex- 
amination showed  a  large  tumor  in  the  hollow  of  the  sacrum,  marked 
elevation  of  the  os  uteri  above  the  symphysis,  and  a  fluctuating  tumor 
in  the  hypogastric  region,  reaching  almost  as  high  as  the  umbilicus. 
This  j^hysical  examination  and  the  history  of  fom"  months  amenor- 
rhoea  made  the  diagnosis  of  retroversion  of  the  gravid  uterus  per- 
fectly plain.  What  concerns  us  here,  however,  is  that  the  bladder 
contained  only  about  twentj^-three  ounces  of  urine,  a  less  amount 
than  in  the  previous  instance. 

Case  III. — Along  with  Prof.  Simpson  I  saw  at  the  Maternity 
Hospital  a  patient  with  rigidity  of  os  uteri,  supposed  to  necessitate 
early  application  of  the  long  forceps ;  supra-pubic  inspection  and 
palpation  revealed  a  fluctuating  tumor  bluntly  triangular  in  shape, 
with  the  apex  down.  Exact  measurements  showed  that  vertically  it 
extended  four  inches,  and  transversely  for  about  the  same  distance. 
The  catheter  passed  deeply  up,  and  drew  off  only  two  ounces  and  a 
half  of  clear  urine,  and  some  time  afterward  the  same  apparent  dis- 
tention occurred,  when  three  ounces  and  a  half  were  removed.  Af- 
ter the  bladder  was  thus  emptied,  the  furrow  between  cervix  and 
uterus  could  be  felt  two  fingers'  breadth  above  the  symphysis  pubis. 
These  three  cases  are  typical  instances,  and  evidently  call  for  expla- 
nation. 

In  the  first  case  narrated  the  bladder  was  simply  distended.  It 
had  pushed  the  intestines  up,  tilted  the  uterus  back,  but  its  posterior 
wall  was  still  in  its  normal  position.  The  peritonteum  was  still  on 
the  summit  of  the  bladder,  but,  of  course,  was  stripped  to  a  certain 
extent  from  the  lower  part  of  the  posterior  aspect  of  the  anterior 
abdominal  wall.  Thus  the  bladder,  though  its  summit  was  only  at 
the  level  of  the  brim,  was  considerably  distended.     Now,  in  the 


772  DISEASES  OF  WOMEN. 

retroversion  of  the  gravid  uterus,  the  bladder  was  certainly  distended, 
supi-a- pubic  palpation,  however,  misled  as  to  the  amount  of  disten- 
tion, and  for  the  following  reason  :  Ths  cervix  uteri  wa.s  tilted 
high  up  behind  the  symphysis  pubis,  and  consequently  the  blad- 
der, to  whose  posterior  angle  the  cervix  is  attached,  wafi  swung 
up,  as  it  were,  into  the  abdominal  cavity,  a  movement  permitted  by 
the  anatomical  relations  behind  the  pubis.  The  peritoneal  relations 
were  the  same  as  in  Case  I.  In  the  third  case,  the  bladder  was,  of 
course,  drawn  up,  as  I  have  already  shown,*  and  its  relations  were  as 
follows :  In  front  it  touched  the  anterior  abdominal  wall ;  behind, 
the  child's  head,  the  cervix,  of  course,  intervening.  In  this  way  the 
anterior  and  posterior  vesical  walls  were  in  contact,  and  thus  a  film 
of  urine,  as  it  were,  gave  the  appearance  of  distention.  As  I  have 
before  pointed  out,  the  peritonaeum  is  stripped  off  the  bladder 
more  or  less.f 

The  conclusions  advanced  are  :  1.  The  retro-pubic  anatomical 
attachments  of  the  bladder  admit  of  its  distention  and  passage  up- 
ward. 2.  Supra-pubic  palpation  gives  no  sure  indication  of  the 
amount  of  urinary  distention.  3.  When  the  summit  of  the  blad- 
der is  above  the  pubis,  it  may  be  (a),  a  j)ure  distention  (Case  I ) ;  (b), 
distention  plus  a  tilting  up  (Case  11) ;  (c),  drawing  up  of  the  blad- 
der, with  almost  no  distention  (Case  III). 

The  reason  why  gynecologists  use  a  long  gum-elastic  catheter  is 
very  evident.  I  have  already  described  the  empty  bladder  in  the  non- 
parturient  female  as  forming  a  Y-shaped  ligure  on  vertical  section. 
During  parturition,  however,  the  urethra  is  elongated,  and  forms 
with  the  bladder,  on  vertical  section,  a  continuous  tube.;}:  Only 
that  part  of  the  bladder  above  the  pubis  is  available  for  the  recep- 
tion of  urine,  so  that  in  this  way  the  path  for  the  catheter  to  travel 
is  increased.  In  Braune's  section  of  a  woman  in  labor,  the  distance 
for  the  catheter  to  travel  is  about  four  and  a  half  inches,  more  than 
twice  what  it  is  normally. 

In  the  last  place,  the  distended  female  adult  l)ladder  is  quite 
comparable  in  its  anatomical  relations  to  the  distended  fetal  one. 
This  may  point  to  the  explanation  that  the  ultimate  changes  which 
convert  the  urinary  bladder  from  an  abdominal  organ  into  a  pelvic 
one  is  chiefly  in  the  bony  pelvis  itself. 

Eetrocession  and  Forward  Transposition  of  the  Uterus. — The  vari- 
ous forms  of  displacement  of  the  bladder  described  thus  far,  ai'e  usu- 

*  "Edinburgh  Medical  Journal,"  April,  1879. 

f  "Edinburgh  Medical  Journal,"  September,  1879,  "Edinburgh  Obstetrical  Transac- 
tions "  (Pait  II,  p.  142).  I  See  "  Die  Lage  des  Foetus,"  Braunc,  Tab.  C. 


NON-INFLAMMATORY  DISEASES  OF  THE   BLADDER.       ^TS 


ally  associated  with  uterine  dislocations,  and  are  familiar  to  those 
who  have  given  attention  to  gynecology.  There  remains  to  be  no- 
ticed two  forms  of  displacement  of  the  uterus  not  generally  described 
by  authors,  but  which  markedly  disturb  the  functions  of  the  blad- 
der, viz.,  retrocession  und/orward  transposition.  In  the  first  form, 
the  uterus,  without  any  change  in  the  relation  of  its  axis  to  the 
plane  of  the  superior  pelvic  strait,  is  found  to  rest  far  back  in  the 
pelvis,  and  is  fixed  there.  In  the  second  form,  the  reverse  of  this 
exists,  the  uterus  resting  just  beliind  the  pubes.  Figs.  240  and  241, 
will  show  these  conditions. 

The  best  example  of  retrocession  I  have  ever  seen  was  in  a  pa- 
tient who  had  had  a  severe  pelvic  peritonitis  sonietirae  before  she  came 
to  me.  The  uterus  was  firmly  fixed  in  the  posterior  portion  of  the 
pelvis,  and  the  bladder  was  drawn  backward,  and  was  exceedingly 
ii-ritable.     This  condition  caused  her  great  trouble,  as  she  could  never 


Fig.  238. 


-Forward  transposition  of  the  uterus.     The  bladder  will  be  seen  somewhat  flat- 
tened against  the  pubc.s,  and  the  urethra  pushed  out  of  its  axis. 


completely  empty  the  organ,  except  when  the  catheter  was  used. 
Owing  to  the  fixation  of  these  organs  in  their  malposition,  it  was 
impossible  to  relieve  her  from  the  frequent  and  difficult  urination, 
and  she  remained  a  great  sufferer,  until  she  died  of  phthisis  pul- 
monalis. 


DISEASES   OF   WOMEN. 


To  illustrate  the  forward  transposition,  I  may  mention  a  case 
that  came  under  my  notice  several  years  after  she  had  had  an  intra- 
peritoneal pelvic  haemutocele.     Her  physician  told  me  that  she  had 


Fig.  239. — Retrocession  of  the  uterus.     The  vagina  is  here  found  lengthened,  and  the 
bladder  and  urethra  pulled  upward  and  backward,     a,  adhesions,  b,  bladder. 

severe  inflammation  following  the  internal  haemorrhage,  and  nearly 
lost  her  life  therefrom.  She  was  confined  to  her  bed  for  many 
months,  and  after  recovery  she  suffered  from  frequent  urination. 
Night  and  day  she  was  obliged  to  pass  water  every  two  hours,  and 
if  she  went  longer  than  that,  she  had  pain  which  was  not  relieved 
till  some  time  after  emptying  the  bladrler.  The  uterus  was  situated 
at  its  proper  elevation,  and  was  just  behind  the  pubes.  The  bladder 
was  compressed  from  before  backward,  and  (as  the  uterus  was 
lirraly  fixed  in  its  forward  position)  of  course  it  could  never  be 
fully  distended.  There  was  no  disease  of  the  bladder,  so  far  as  could 
be  ascertained  from  an  examination  of  the  urine,  or  of  the  organ 
itself.  No  treatment  that  was  employed  gave  anything  more  than 
temporary  relief. 

(/)  Inversion  of  the  Bladder.— This  affection  stands  next  in  rai-ity 
of  occurrence  to  complete  prolapsus  of  the  bladder  through  a  fissure 
in  the  abdominal  walls.  It  is  sometimes  denominated  as  extrover- 
sion of  the  bladder  through  the  urethra. 


NON-INFLAMMATORY   DISEASES  OF  THE  BLADDER.       775 

By  some  authors  it  is  supposed  to  be  a  simple  protrusion  of  the 
mucous  coat  of  the  bladder  through  the  urethra,  but  by  others  to  be 
a  prolapse  of  the  whole  organ.  In  support  of  the  latter  belief  is  the 
fact  that  after  death  Joubert,  Rutly  aud  Leoret  found  a  sinking  in 
or  partial  inversion  of  the  whole  organ.  Moreover,  Meckel  claims  to 
have  found  under  the  labia  minora,  and  protruding  from  the  meatus 
a  mass  of  tissue  that  on  careful  examination  proved  to  consist  of  all 
the  elements  of  the  several  coats  of  the  bladder. 

Burns  thinks  it  much  easier  for  a  prolapse  of  the  whole  organ  to 
take  place  than  a  separation  and  prolapse  of  the  mucous  membrane 
alone.  Streubel,  after  a  careful  review  of  the  literature  of  the  sub- 
ject, was  able  to  find  but  one  case  in  which  the  mucous  membrane 
was  alone  prolapsed.  As  the  posterior  vesical  wall  in  the  empty 
organ  lies  over  the  vesical  opening  of  the  urethra,  it  is  easy  to  com- 
j)rehend  how  this  dislocation  might  occur  from  sudden  straining 
efforts,  pressure  of  the  overloaded  colon,  or  pressure  of  a  heavy 
uterus.  Vesical  tumors  with  long  pedicles  coming  out  through  the 
urethra,  by  weight  or  from  traction,  might  produce  this  result. 
The  process  of  extroversion  is  generally  slow.  De  Haen,  quoted  by 
Streubel,  gives  a  case,  however,  where  from  force,  the  bladder,  rec- 
tum, and  vagina  were  all  prolapsed  together.  It  will  be  understood 
that  in  order  to  have  the  bladder  turned  inside  out,  the  urethra  must 
be  abnormally  dilated. 

It  may  occur  at  any  age.  Weinlecher  saw  it  in  a  child  but  nine 
months  old ;  OKver,  in  one  of  sixteen  months ;  Crobs,  in  one  from 
two  to  three  years ;  Streubel,  in  a  girl  fourteen  years  old ;  and  Thom- 
son and  Percy,  in  women  aged  respectively  forty  and  fifty -two. 

Symptomatology. — The  patients,  even  before  the  tumor  appears, 
feel  strong  pressure  in  the  organ  on  urination,  and  may  have  stop- 
pages in  the  stream  and  retention.  After  a  time  these  symptoms 
become  aggravated,  a  small  red  tumor  appears  at  the  meatus,  and 
with  each  urination  enlarges.  With  the  appearance  of  the  tumor 
comes  pain.  In  some  cases,  when  the  desire  to  urinate  is  felt,  severe 
contraction  of  the  bladder  takes  place,  but  no  urine  flows.  Then 
suddenly  the  little  tumor  disappears  inside,  and  the  urine  flows  freely. 
With  each  appearance  of  the  tumor  there  is  considerable  constitu- 
tional disturbance,  and  after  a  time  the  appetite  is  lost,  and  the  suf- 
ferers emaciate  rapidly.  From  continual  traction  on  the  ureters, 
they  may  become  inflamed,  and  also  the  kidneys,  and  urremia  super- 
vene. Blood  is  sometimes  pas-ed  with  the  urine.  Cystitis  may 
occur,  which  increases  the  suffering  and  danger.  The  mucous  mem- 
brane may  become  hypertrophied,  congested,  aud  even  oedematous. 


776  DISEASES  OF  WOMEN. 

The  constitutiona]  symptoms  bear  no  relation  to  tlie  amount  of  tissue 
extruded  or  the  area  of  mucous  surface  ex]>osed. 

Diagnosis. — Fortunately,  this  allectioii  is  a  rare  one,  for  the  diag- 
nosis is  by  no  means  easy.  The  surface  of  the  tumor  should  be  ex- 
amined, and  the  nature  of  its  epithelium  carefully  noted.  Reduc- 
tion should  he  tried,  and,  if  successful,  examination  should  be  made 
by  the  sound  in  the  bladder,  and  the  finger  in  vagina  or  rectum  (the 
latter  in  infants),  to  ascertain,  if  possible,  whether  there  be  any  thick- 
ening of  the  membrane  or  a  tumor  in  the  viscus.  If  on  the  surface 
of  the  protrusion  the  orifices  of  the  ureters  can  be  found,  the  diag- 
nosis is  at  once  settled.  Polypoid  projections  of  the  mucous  mem- 
brane must  be  differentiated  from  protrusion  of  the  viscus  itself. 
Such  cases  are  described  by  Baillie  and  Patron. 

From  prolapsus  of  the  urethral  mucous  membrane,  which  I  shall 
hereafter  describe,  this  condition  is  to  be  differentiated  by  the  absence 
in  the  latter  of  the  ureteric  openings  and  the  position  of  the  meatus 
urinarius.  In  urethral  prolapse  the  orifice  is  situated  either  centrally 
or  superiorly,  while  in  vesical  protrusion  the  meatus  surrounds  the 
pedicle.  In  the  latter  there  is  a  large  strong  pedicle  ;  in  the  foraier 
none. 

Treatment. — The  treatment  naturally  divides  itself  into  prophy- 
lactic and  curative.  To  prevent  partial  extroversion  from  becoming 
complete,  narcotics  and  demulcents  should  be  given  by  the  mouth 
and  rectum,  or  injected  into  the  bladder.  Opium,  hyoscyamus,  and 
belladonna  may  all  be  tried.  Local  cauterization  and  washing  out 
with  tonic  injections  might  prove  serviceable.  These  preventive 
means  are  usually  sufficient,  provided  the  urine  is  normal  and  the 
mucous  membrane  healthy.  If  either  of  these  abnormalities  exist, 
they  should  be  corrected. 

If  the  tumor  is  down,  its  reposition  should  be  attempted.  Gentle 
manipulation  with  the  finger  should  be  tried,  and,  if  the  mass  can 
not  be  put  back  in  this  way,  a  well-oiled  blunt  catheter  should  be 
used,  making  pressure  with  it  in  the  direction  of  the  axis  of  the 
urethra.  If  this  is  very  painful,  and  there  are  spasmodic  contrac- 
tions of  the  abdominal  muscles,  which  prevent  replacement,  the 
patient  should  be  etherized,  and  success  may  then  follow.  She  should 
be  on  her  back,  or  in  the  Sims's  position. 

To  prevent  prolapse  after  reduction,  the  catlieter  may  remain  in 
situ  for  a  time,  or  the  colpeurynter  or  tampon  may  be  used.  Schatz's 
pessary  for  urinary  incontinence  may  be  employed  advantageously, 
as  its  use  tends  to  contract  the  vesical  neck.  Astringent  injections 
may  be  used.     No  operative  procedure  is  required. 


CHAPTER   XLIIL 

NON- INFLAMMATORY   DISEASES    OF   THE   BLADDER    (CONTINUED). 
FOREIGN   BODIES   IN   THE   BLADDER. 

Foreign  bodies  found  in  the  female  bladder  are  divided  into  three 
classes  by  Winckel,  as  follows  : 

{a)  Those  that  come  from  the  body,  entering  the  bladder  by  per- 
foration. 

(h)  Those  which  have  their  origin  in  the  bladder. 

{&)  Those  that  are  introduced  from  without  through  the  urethra. 
I  will  adopt  this  classification,  believing  it  to  be  the  most  natural 
and  convenient. 

(a)  First  then,  as  to  those  that  come  from  the  body,  entering  the 
bladder  by  perforation. 

That  cysts  ever  originate  in  the  bladder  is  doubted  by  some  and 
denied  by  others.  In  most  cases  where  they  are  found  in  this  organ 
they  can  be  traced  to  dermoid  cysts  of  the  ovary  which  have  found 
their  way  into  it,  thus  accounting  for  the  presence  of  hair,  teeth,  and 
other  tissues  in  this  viscus.  These  things  are  never  found  there 
unless  such  a  cyst  has  opened  into  the  bladder.  The  contents  of 
these  dermoid  cysts  may  become  nuclei  for  calculi,  and  lead  to  seri- 
ous trouble. 

I  think  there  can  be  no  doubt  but  that  some  of  the  cysts  found 
in  the  bladder  have  their  origin  there.  Mucous  follicles  certainly 
do  exist  in  the  bladder,  and  are  liable  to  have  their  orifices  blocked 
or  occluded,  and  by  secretion  behind  the  point  of  obstruction  grad- 
ually form  cysts.  Interestmg  cases,  where  the  cysts  evidently  had 
their  origin  in  the  bladder  itself,  are  related  by  Paget,  Liston,  and 
Campa.  It  is,  however,  undoubtedly  the  fact  that  most  cysts  of  the 
bladder  have  their  origin  outside  that  organ. 

Cysts  of  the  ureters  and  urachus  may  open,  into  the  bladder. 
Hydatid  cysts  have  been  found,  but  are  less  frequently  seen  in  this 


778  DISEASES   OF   WOMEN. 

country  than  in  almost  any  other.  Iceland  is  especially  cursed  with 
them,  about  one  sixth  of  the  j)opulation  Kuffenn<5  from  tliem  in  some 
part  of  the  body.  They  may  appear  in  the  urine,  white  and  pearly 
in  appearance,  or  be  of  a  dirty  yellowish  color,  from  prolonged  soak- 
ing in  foul  urine. 

Treatment. — These  cysts,  or  their  contents,  if  giving  rise  to  any 
trouble,  should  be  treated  in  the  same  manner  as  the  neoplasms,  of 
whicli  I  shall  speak  later. 

In  the  treatment  of  hydatid  cysts,  iodide  of  potassium  has  been 
especially  recommended.  Having  never  had  occasion  to  use  it  for 
this  purpose,  I  can  say  verj-  little  for  or  against  it. 

Other  Foreign  Bodies. — Various  parts  of  the  fcetus  have  found 
their  way  into  the  bladder  by  ulceration  during  extra-uterine  preg- 
nancy, and  pieces  of  ulcerated  intestine,  masses  of  feces,  fecal  con- 
cretions, and  biliary  concretions,  are  some  of  the  curious  things  that 
have  been  found  in  this  viscus.  In  gun-shot  and  other  injuries  to 
the  pelvic  bones,  osseous  splinters  have  found  their  way  into  the 
viscus,  and  been  evacuated  through  the  uretlira,  or  have  passed  into 
the  vagina  or  rectum  by  ulceration,  or  have  remained,  forming  nuclei 
for  calculi. 

Various  parasites  may  penetrate  the  walls  from  the  immediate 
tissue  or  neighboring  organs,  or  come  down  from  the  kidneys,  such 
as  the  echinococci,  already  spoken  of,  the  distoma  haematobium  or 
the  iilaria  sanguinis  hominis.  Joints  of  tape-worm,  the  ascaris  lum- 
bricoides,  and  the  thread-  or  seat-worms  have  also  been  found  here, 
entering  either  through  a  fistulous  opening,  existing  between  the 
bladder  and  intestine,  or  through  the  urethra. 

In  acute  destructive  change  in  the  kidneys  (pyonephrosis  and 
abscess),  pus  and  pieces  of  renal  tissue  are  not  unfrequently  carried 
down  into  the  bladder,  and  ma}',  by  frequent  incrustation  with 
the  urinary  salts,  result  in  the  formation  of  calculi.  Of  themselves, 
they  give  rise  to  very  little,  if  any,  irritation,  and  are  consequently 
of  no  importance  save  in  relation  to  the  destructive  changes  going 
on  in  the  kidney,  of  which  they  tell  the  story.  If  such  discharges 
from  the  kidneys  continue  for  a  long  time,  they  cause  cystitis. 

Renal  calculi  may  become  dislodged,  and  be  swept  down  into  the 
bladder,  there  to  enlarge  by  further  incrustations,  or  pass  out  through 
the  urethra. 

Symptomatology. — The  symptoms  of  the  various  foreign  bodies 
in  the  bladder  differ  only  in  degree.  They  are  at  first  those  of  irri- 
tation ;  later  those  of  acute  or  subacute  inflammation.  Bodies  round, 
smooth,  and  soft,  are,  of  course,  less  irritant  than  those  that  are  rough 


NON-INFLAMMATORY   DISEASES   OF  THE   BLADDER.       779 

or  sharp.  Cysts,  tlierefore,  bits  of  flesh,  aud  their  liiie,  as  a  rule, 
give  rise  to  no  very  severe  symptoms,  while  splinters  of  bone  and 
calculi  occasion  much  more  severe  manifestations.  Pain  and  tenes- 
mus will  vary  with  the  character  of  the  offending  body.  If  the 
mucous  surface  be  abraded  or  torn,  hsematuria  will  result ;  and,  if 
the  foreign  body  remains  in  the  organ,  and  continues  to  irritate  it, 
cystitis  will  follow,  and  the  patient  suffer  increased  agony. 

The  extension  of  the  inflammation  upward,  and  involvement  of 
one  or  both  kidneys,  will  give  rise  to  pain  in  the  back,  hectic  fever, 
partial  or  total  suppression  of  urine,  and  consequent  urasmic  symp- 
toms, ending  fatally. 

The  urine  shows  the  various  appearances  of  cystitis,  of  which 
suflicient  has  already  been  said,  and  also  the  signs  of  renal  involve- 
ment, if  such  be  present. 

Treatment. — Any  foreign  body,  when  known  to  be  present  in 
the  bladder,  should  be  removed  at  as  early  a  date  as  possible.  In 
the  adult  female  this  may  be  readily  accomplished  by  dilatation  of 
the  urethra,  or,  if  the  body  be  too  large,  by  Simon's  vesico-vaginal 
section. 

In  cases  of  fistulous  communication  between  the  bladder  and  in- 
testine or  other  organ,  an  attempt  should  be  made,  in  the  mamier 
already  spoken  of,  to  close  the  opening. 

Echinococci  and  other  parasites  should  be  treated  with  the  vari- 
ous remedies  recommended  for  their  destruction  elsewhere,  always, 
however,  removing  the  offending  body  from  the  bladder  first,  and 
trying  to  prevent  further  invasion  by  proper  medication. 

If  cystitis  be  present,  this  will  be  attended  to  in  the  prescribed 
way. 

Hydatids  in  the  Bladder. — Dr.  J.  A.  McKennion,  of  Selma,  Ala- 
bama, reported  a  case  in  the  "  American  Medical  Weekly,"  Louisville, 
Kentucky,  in  1874  or  1875.  The  purport  of  this  report,  according 
to  my  recollection,  is  that  it  was  a  case  which,  when  first  seen,  had 
every  indication  of  cystitis,  with  great  thickening  of  the  walls  of  the 
bladder.  Frequent  micturition  caused  the  patient  to  exclude  her- 
self from  society  for  two  years  before  a  correct  diagnosis  of  the  case 
was  formed.  She  was  becoming  prostrated  from  constant  dysuria, 
and,  in  order  to  give  her  quietude,  Dr.  McKennion  says,  I  attempted 
to  introduce  a  Sims's  catheter,  to  be  ret"ained  during  the  night ;  but, 
meeting  with  an  obstruction  in  the  bladder,  and,  by  manipulation 
with  catheter,  finding  that  she  was  insensible  as  to  the  point  of  the 
instrument,  I  concluded  that  a  hydatid  formation  was  present,  and 
designed  at  once  to  have  it  expelled  if  possible. 


780  DISEASES  OF   WOMEN. 

I  would  say  here  one  of  the  strongest  arguments  in  my  own  mind 
at  the  time  of  hydatid  formation  was,  when  force  was  used  to  pusli 
up  the  instrument  fartlier,  a  small  amomit  of  liuid  escaped,  and  no 
blood.  I  injected  into  the  bladder  two  drachms  of  liq.  sodae  chlor. 
(French  preparation).  In  about  an  hour  violent  spasms  of  the  blad- 
der occurred,  the  urethra  dilated,  and  there  was  expelled  into  the 
vessel  about  a  pint  of  hydatid.  The  shape  and  attachment  of  these 
resembled  the  cactus ;  the  sacs  were  transparent  and  well  dcHned. 
There  was  but  slight  haemorrhage.  This  I  attributed  to  the  forciljle 
distention  of  the  urethra.  It  is  now  over  five  years  since  their  ex- 
pulsion, and  up  to  this  day  my  patient  has  had  no  more  inconven- 
ience with  her  bladder.  Fortunately,  my  case  was  a  female,  and 
she  is  well ;  this  might  not  have  been  if  it  had  been  one  of  our  own 
sex.—Ji^eiv  Yor'k  Medhal  Record,  Xovemher  20,  lSSO,p.  588. 

(b)  Bodies  having  their  Origin  in  the  Bladder  Itselt — Under  this 
head  come  calculi,  which  may  be  of  various  kinds,  as  uric  acid,  triple 
and  amorphous  phosphates,  oxalate  of  lime,  and  cystine.  The  latter 
are  quite  rare.  Again,  the  calculi  may  consist  of  more  than  one  of 
these  ingredients. 

Time  will  not  allow  me  to  enter  into  the  extensive  field  embrac- 
ing the  etiology  and  treatment  of  stone.  For  a  comprehensive  study 
of  this  matter,  I  must  refer  the  reader  to  any  one  of  the  many  excel- 
lent works  on  that  subject. 

Calculus. — I  shall  only  speak  of  one  or  two  points  in  connection 
with  calculus  that  are  of  especial  interest  in  the  study  of  disease  of 
the  female  bladder.  Stone  in  the  bladder  is  not  so  common  among 
women  as  among  men.  This,  I  presume,  is  o^-ing  to  the  large  and 
easily  dilatable  urethra  of  the  female,  which  permits  small  renal  cal- 
culi to  pass  out ;  calculi  of  the  same  size  in  the  male  being  retained 
in  the  bladder,  and  serving  as  nuclei  for  larger  ones. 

Symptomatology. — The  symptoms  are  simply  those  of  a  foreign 
body  in  the  bladder,  varying  with  the  size,  shape,  and  number  of 
the  stones,  and  also  their  roughness  of  surface.  Frequent  urina- 
tions, tenesmus,  pain  before,  during,  and  after  urination,  some- 
times incontinence,  and  always  more  or  less  cystitis.  Hgematuria  is 
not  at  all  infrequent,  and  the  urine  presents  all  the  characters  of 
bladder  inflammation,  as  shown  by  the  presence  of  pus,  epithelium, 
and,  sooner,  or  later,  numerous  crystals  of  the  tiiple  and  amorphous 
phosphates. 

The  constitution  suffers  from  the  constant  pain  and  frequent 
urination,  and  the  patient  gives  all  the  symptoms  of  a  severe  cystitis. 

Diagnosis. — This  is  comparatively  easy  in  the  female  bladder, 


NON-INFLAMMATOPwY  DISEASES  OF  THE  BLADDER.       781 

for  between  the  judicious  use  of  the  sound,  conjoined  manipulation, 
and  the  bladder  speculum,  a  stone  can  hardly  escape  detection  un- 
less it  be  very  small  or  completely  encysted. 

Pi'ognosis. — The  prognosis  in  vesical  calculus  in  women  is  good, 
provided  the  kidneys  be  not  seriously  disordered.  The  cystitis  usu- 
ally disappears  soon  after  removal  of  the  foreign  body,  under 
proper  treatment ;  and  even  if  renal  disease  exist,  it  may  also  sub- 
side. 

Causation. — The  causes  of  stone  in  the  bladder  are  about  the 
same  in  both  sexes,  and  so  I  need  not  dwell  long  on  tliis  part  of  the 
subject,  I  may  call  attention  to  one  cause  of  the  formation  of 
stone  in  the  bladder  of  the  female.  In  cystocele,  a  mass  of  mucus 
or  shreds  of  membrane  and  triple  and  amorphous  phosphates  gradu- 
ally collect  in  this  abnormal  pouch,  and  form  a  nucleus  for  stone. 
It  is  a  curious  fact,  too,  that  women  are  particularly  liable  to  have 
stone  after  the  operation  for  closure  of  vesico-vaginal  iistula.  There 
has  been  considerable  discussion  as  to  whether  calculi,  discovered 
soon  after  this  operation,  existed  undiscovered  in  the  bladder  before 
the  operation,  or  were  formed  rapidly  after  it.  Henry  F.  Camp- 
bell, M.  D.,  of  Virginia,  relates  one  case  in  favor  of  the  former 
view,  and  Dr.  T.  A.  Emmet  several  in  favor  of  the  latter. 

The  belief  has  been  advanced  that  irritation  in  the  bladder  mod- 
ifies the  urinary  secretion  sufficiently  to  cause  deposit  of  the  urin- 
ary salts,  and  thus  account  for  the  formation  of  stone  after  the 
operation  for  fistula.  It  is  claimed  that  reflex  nerve  action  is  ex- 
cited by  the  operation,  the  inflammatory  action  about  the  edges  of 
the  wound,  or  by  cystitis  already  existing. 

This  idea  that  the  reflex  nerve  influence  modifies  the  urinary  se- 
cretion sufficiently  to  result  in  the  formation  of  stone  in  these  cases, 
is,  I  think,  hardly  tenable ;  for  in  hundreds  of  cases  of  cystitis, 
where  the  reflex  action  does  undoubtedlj^  exist,  no  stone  is  formed. 
Then,  too,  the  secretion  is  as  a  rule  rendered  more  watery,  instead 
of  concentrated,  a  condition  in  which  precipitation  of  tlie  urinary 
salts  would  be  very  unlikely  to  take  place. 

A  middle  position  on  this  question  seems  to  me  to  be  the  most 
rational,  and  stones  found  after  operations  for  closing  fistula  might 
be  due  to  any  one  of  three  causes  : 

(«)  Calculus  already  existing  in  the  bladder,  escaping  detection  by 
being  pocketed,  or  so  small  as  to  lie  beneath  a  mucous  fold,  and 
rapidly  increasing  in  size  after  operation,  due  to  the  retention  of  the 
salts  of  the  urine  (deposited  by  decomposition),  that  formerly  es- 
caped by  means  of  the  fistula. 


782  DISEASES   OF   WOMEN. 

(J)  Calculi,  small  or  large,  existing  in  the  kidneys  or  renal  pelves, 
and  washed  down  after  the  operation  In-  the  increased  flow  of  limpid 
urine :  these,  too,  increasing  in  size  hy  incrustation. 

(c)  Calculi,  the  formation  of  which  commences  directly  after 
closure  of  the  wound,  due  partly  to  retained  products  of  decomposi- 
tion, possibly  to  modified  secretion,  or  to  small  nuclei  swept  down 
from  the  kidney,  or,  what  is  much  more  likely,  to  nuclei  consisting 
of  pieces  of  mucous  shreds,  blood-clots,  or  po.ssibly  incrustations  on 
one  or  more  of  the  sutures  which  may  be  exposed  in  the  bladder. 

I  am  quite  sure  tliat  the  formation  of  calculi  after  closing  a  ves- 
ico-vaginal  fistula  is  favored  by  the  presence  of  the  catheter  in  the 
bladder  during  the  healing  process.  The  drainage  is  imperfect  and 
if  the  bladder  is  not  frequently  washed  there  is  every  facihty  for  the 
deposit  of  urinary  salts  and  the  formation  of  stone.  I  am  the  more 
persuaded  that  tliis  explanation  is  correct  from  the  fact  that,  since  I 
have  permitted  my  patients  to  empty  the  bladder  in  the  natural  way 
after  the  operation,  I  have  not  had  a  case  of  stone  following  this 
operation. 

Treatment. — The  female  bladder  presents  an  inviting  field  for 
experiments  on  the  treatment  of  stone  by  solvents  ;  but  as  the  opera- 
tion here  is  so  easy  and  its  results  so  good,  it  seems  hardly  justifiable 
to  recommend  any  other  method  of  treatment.  In  patients,  how- 
ever, who  object  to  the  operation,  it  may  be  tried.  For  a  full  and 
interesting  account  of  experiments  and  statistics  on  the  solvent 
method,  I  refer  to  Mr.  Koberts's  most  excellent  work  on  "  Urinary 
and  Renal  Diseases," 

The  stone  being  found  and  its  size  determined,  it  may  either  be 
removed  by  cystotomy  or  crushed.  If  the  stone  be  small  and  soft, 
it  may  be  advisable  to  crush  it,  washing  out  the  fragments  through 
the  open  speculum  in  the  moderately  dilated  urethra,  thus  saving 
the  urethral  mucous  membrane  from  laceration  by  the  sharp  frag- 
ments ;  or  better  still  the  debris  may  be  removed  by  Bigelow's 
method. 

If  much  cystitis  be  present,  however,  or  if  the  stone  be  large,  it 
is  advisable  to  perform  vaginal  cystotomy.  In  this  way  a  stone  of 
large  size  may  be  removed  from  any  ])art  of  the  bladder,  and  an 
opening  for  drainage  is  left  to  act  beneficially  on  the  inflamed  organ 
by  giving  vent  to  the  urine  and  its  sediment.  The  bladder  should 
be  carefully  washed  out  daily  with  a  warm  solution  of  salicylic  acid 
(1  to  600  or  1  to  400).  If  drainage  is  desired,  care  must  be  taken  to 
keep  the  incision  open,  for  it  closes  very  readily. 

I  have  spoken  several  times  already  as  to  the  method  of  per- 


NOX-mFLAMMATORY  DISEASES   OF  THE  BLADDER.       783 

forming  vaginal  cystotomy.  Emmet  dwells  especially  and  justly  on 
the  necessity  of  fixing  the  vesico-vaginal  wall  rirmly  with  a  tenacu- 
Jmn  before  commencing  the  incision,  which  may  be  made  with 
either  a  knife  or  scissors.  A  calculus  in  the  bladder,  if  interfenng 
with  labor,  or  if  liable  to  be  caught  between  the  child's  head  and 
the  pubes,  should,  if  possible,  be  pushed  up  out  of  the  way.  This  is 
seldom  successful,  and  as  much  damage  may  be  done  the  bladder  by 
the  crushing  of  its  walls,  it  is  best  to  puncture  and  remove  the  stone 
at  once  in  case  there  is  time  during  the  labor  and  the  attendant  is 
prepared  to  operate.  Should  it  be  impossible  to  operate  before 
labor  is  completed,  it  should  be  done  as  soon  afterward  as  practi- 
cable. It  should  be  borne  in  mind  that  the  vascularity  is  greater  in 
the  puerperal  state  and  hence  every  preparation  should  be  made  to 
arrest  li£emorrhage. 

ILLUSTRATIYE    CASES. 

Foreign  Bodies  in  the  Bladder. — By  L.  H.  Dunning,  M.  D. ;  read 

before  the  "  Indiana  State  Medical  Society  "  : 

Case  I. — Mrs.  A.,  aged  thirty-eight,  married,  a  lady  of  culture 
and  refinement,  was  delivered,  four  years  previously,  of  a  liydro- 
cephaloid  child.  The  delivery  was  instrumental.  "Whether  from 
long  pressure  of  an  abnormally  large  head,  or  from  maladroit  use 
of  instruments,  I  know  not,  a  vesico-uterine  or  vaginal  fistula  re- 
sulted. The  precise  location  of  the  original  opening  of  the  vaginal 
or  uterine  extremity  of  the  fistula  I  am  unable  to  state,  as  two 
operations  had  been  done  for  its  closure,  both  of  which  were  un- 
successful. The  last  operation  was  done  in  June,  1883,  and  in 
the  following  December  I  was  consulted  in  consequence  of  intense 
pain  and  burning  in  the  region  of  the  bladder,  and  pain  at  the 
close  of  the  act  of  urinating.  The  patient  stated  she  had,  a  few 
weeks  previously,  passed  a  small  stone  by  the  urethra,  and  now 
thought  there  was  another  and  larger  one  present.  An  examination 
with  the  sound  confirmed  her  diagnosis.  I  proceeded  to  remove 
the  stone,  assisted  by  Dr.  S.  L.  Kilmer.  The  urethra  was  dilated 
with  a  three-bladed  dilator,  the  stone  crushed  with  a  Thompson's 
lithotrite,  and  removed  with  Bigelow's  evacuating  apparatus.  We 
were  both  confident  all  the  stone  was  removed.  The  patient  made 
a  good  recovery,  but  was  not  entirely  relieved  of  the  bladder  symp- 
toms. In  March,  18S4,  I  was  again  called  to  remove  a  stone,  w^hich 
the  patient  stated  she  had  felt  with  the  lai"ge  end  of  a  shawl-pin  in- 
troduced into  the  bladder  through  the  urethra.  This  time,  assisted 
by  Dr.  M.  L.  Morse,  a  large  quantity  of  stone  was  removed  in  the 
same  manner  as  at  the  first  operation.    The  lithotrite  was  introduced 


784  DISEASES   OF    WOMEX. 

tliree  times,  and,  the  last  time  it  was  withdrawn,  we  found  within 
the  grasp  of  its  closed  blades  a  silver-wire  suture,  with  the  loop  cut, 
but  the  twist  intact.  The  whole  was  coated  with  a  phosphate-of-lime 
deposit.  We  now  felt  confident  we  had  secured  the  foreign  body 
around  which  the  calculus  had  collected.  The  patient  stated  to  us 
that  she  had  been  aw'are  ever  since  the  last  operation  for  iistula  that 
there  was  a  wire  left  behind,  and  that  she  had  once  visited  the  sur- 
geon to  have  it  removed,  but  it  could  not  be  found.  There  are 
many  other  points  of  exceeding  interest  connected  with  this  case, 
but  they  are  not  pertinent  to  this  subject,  hence  will  be  omitted. 
There  was  a  band  of  dense  cicatricial  tissue  extending  transversely 
across  the  fundus  of  the  bladder.  Posterior  to  this  band  was  a 
pocket,  in  the  bottom  of  which  was  the  vesical  extremity  of  the  fist- 
ula. In  this  pocket  lodged  the  stone,  and  was  evidently  made  sta- 
tionary by  the  suture,  which  remained  partly  imbedded  in  the  tissues. 
That  the  wire  rendered  the  stone  stationary  finds  support  in  the  fact 
that,  July  18th,  four  months  after  the  wire  was  removed,  a  fourth 
large  calculus  had  formed  in  the  bladder,  and  was  quite  movable. 
This  last  calculus  was  readily  crushed,  and  voluntarily  expelled  from 
the  bladder  along  with  water  freely  injected  into  the  organ.  Since 
this  fourth  stone  was  removed,  there  have  been  no  signs  or  symp- 
toms of  a  calculus  in  the  bladder. 

Case  IT. — Mr.  B.,  a  laborer,  aged  fifty-seven  years,  was  brought 
to  me,  by  Dr.  Kettring,  September  19th,  of  last  year,  for  the  re- 
moval of  a  foreign  body  from  the  bladder.  The  patient  stated  that, 
about  the  niiddle  of  August,  he  passed  a  cigarette-holder  into  the 
orifice  of  the  urethra ;  that  it  slipped  away  from  him,  and  passed 
down  into  the  urethra,  and,  in  his  efforts  to  remove  it,  pushed  it 
into  the  bladder.  Being  a  mechanic,  he  had  invented  an  instrument 
with  which  he  attempted  to  remove  the  body,  without  success.  I 
sounded  the  bladder,  and  found  the  holder  lying  obliquely  across 
the  organ.  I  judged  it  to  be  about  two  and  one  half  inches  long, 
and  as  thick  as  a  small  lead-pencil.  A  Xo.  1 8^  sound  dropped  readily 
into  the  bladder,  and,  since  the  urethra  was  of  so  large  a  caliber,  and 
the  patient  had  frequently  passed  his  instrument  along  its  track,  I 
concluded  to  attempt  its  removal  without  further  dilatation.  A 
Thompson's  lithotrite  was  introduced,  and  the  body  seized ;  but  I 
was  made  conscious  that  the  instrument  did  not  grasp  it  at  the  end, 
so  I  withdrew  the  lithotrite  and  introduced  a  sound,  and  endeavored 
to  bring  the  long  diameter  of  the  holder  in  line  with  the  urethra. 
Now,  with  l)ut  little  difficulty,  the  end  was  grasped  by  the  blades 
of  the  lithotrite,  and  I  proceeded  to  withdraw  the  whole.     It  soon 


NON-INFLAMMATORY   DISEASES   OF  THE   BLADDER.       785 

became  evident  that  we  had  not  rightly  estimated  the  size  of  the 
holder,  for,  although  it,  together  with  the  instrument,  entered  the 
prostatic  portion  of  the  urethra,  we  had  considerable  difficulty  in 
making  it  advance  through  the  membranous  portion.  However, 
avoiding  much  force,  but  keeping  steadily  at  work,  wath  the  aid  of 
Dr.  Kettring,  I  succeeded  in  witlidrawing  it  to  within  one  inch  and 
a  half  of  the  orifice  of  the  urethra.  Further  than  this  we  could 
not  advance ;  so  the  urethra  was  incised  posteriorly  down  to  the  end 
of  tlie  holder,  and,  by  applying  pressure  from  behind,  made  to  enter 
the  incision,  and  was  finally  entirely  withdrawn.  We  were  surprised 
to  see  the  size  of  the  holder  and  its  breadth  when  in  the  grasp  of  the 
lithotrite,  thirty-five  millimetres.  There  was  a  moderate  amount  of 
haemorrhage  from  the  urethra  or  bladder;  probably  from  tlie  mem- 
branous portion  of  the  urethra,  since  that  is  the  most  constricted  por- 
tion of  the  canal.  The  bladder  was  washed  out  with  tepid  water, 
and  the  patient  taken  to  his  home  in  a  closed  carriage,  the  operation 
having  been  done  at  my  office  on  account  of  the  patient's  refusing  to 
have  it  done  at  home  for  fear  of  exposure.  Soon  after  reaching 
home,  the  patient  had  a  chill,  followed  by  fever.  In  the  next 
twenty-four  hours  he  had  three  chills,  each  time  followed  by  in- 
creased fever,  the  temperature  ranging  from  102°  to  101°  F.  The 
urine  passed  was  freely  mixed  with  a  considerable  quantity  of  mucus 
and  a  little  blood. 

20th,  1.30  p.  M. — Patient  seen  by  Dr.  Kettring  and  myself.  Had 
a  temperature  of  106°.  He  voided  urine  in  our  presence ;  it  was 
quite  bloody,  and,  upon  close  examination,  was  found  to  contain  a 
wedge-shaped  piece  of  mucous  membrane  twelve  millimetres  long, 
four  millimetres  broad,  and  about  two  millimetres  thick.  This  was 
not  examined  with  the  glass,  but  was  supposed  to  be  from  the  mem- 
branous portion  of  the  urethra,  since  at  that  point  there  w^as  the  most 
resistance.  There  were  also  voided  at  this  time  several  small  grains 
of  gravel,  some  as  large  as  wheat-grains  Patient  complained  of  con- 
siderable pain.  Bladder  was  washed  out  with  warm  carbolized  water. 
Twenty  grains  of  quinia  sul.  were  given  ;  one  grain  opium  and  ten 
grains  of  acetate  of  potash  every  four  to  six  hours,  and  a  milk-diet 
ordered.  Further  than  this,  I  will  not  attempt  to  minutely  detail  the 
history  of  the  case,  but  will  simply  outline  it.  In  the  next  twenty- 
four  hours  the  patient  had  four  chills.  The  temperature  ranged  from 
101°  to  101°,  and  the  pulse  from  108  to  120  per  minute.  "^  Patient 
perspired  profusely,  and  was  at  times  delirious ;  great  nervousness ; 
prognosis  was  regarded  unfavorable.  Whisky,  in  3  jss  doses,  every 
hour,  when  the  temperature  mounted  high,  was  added  to  the  treat- 
51 


78G  DISEASES   OF   WOMEN. 

ment.  Dr.  Kettring  washed  out  the  bladder  twice  every  day,  using 
for  this  purpose  a  soft-rubber  catlieter  and  a  rubber  bag.  We  de- 
bated the  advisability  of  this  proocdure,  but  found  that,  by  this 
means,  we  removed  a  considerable  quantity  of  turbid  urine,  small 
clots  of  l)lood,  and  occasionally  small  grains  of  gravel ;  and  further, 
the  cleansing  of  the  bladder  seemed  to  afford  tiie  patient  relief ;  so 
we  decided  to  persist  in  it  as  long  as  its  use  was  indicated. 

22d. — Patient  slightly  delirious;  pulse,  112;  temperature,  101°; 
slept  moderately  well  last  night :  has  had  no  chill  since  9  p.  m.  yes- 
terday. Dr.  Kettring  found  morphine,  gr.  one  sixth,  ar.  spts.  ammo., 
3jss,  very  eflScient  in  relieving  or  aborting  the  chills.  At  noon 
to-day  patient  seemed  much  better ;  at  9  p.  m.  temperature  had  fallen 
to  100°,  and  pulse  to  90  ;  Imt  the  urine  had  accumulated  in  the  blad- 
der, and  had  to  be  removed  by  catheterization. 

23d,  7.30  A.  M. — Patient  rational ;  has  slept  well  during  the 
night,  and  voided  urine  frequently ;  pulse  is  70,  and  temperature 
normal ;  the  nervous  symptoms  have  nearly  disappeared  ;  had  symp- 
toms of  a  chill  last  night,  which  quickly  disappeared  under  the  effects 
of  the  morphine  and  ar.  spts.  of  annuo.,  with  the  addition  of  ten 
drops  of  chloroform. 

From  this  time  forward  the  recovery  was  uninternipted.  In  one 
week  the  patient  was  able  to  sit  up.  A  few  days  later  he  was  walk- 
ing about  the  streets,  and  in  two  weeks  after  the  operation  resumed 
work. 

Thus  happily  terminated  a  case  that  at  one  time  was  exceedingly 
alarming,  in  consequence  of  tlie  intense  urethral  fever  that  devel- 
oped. It  would  undoubtedly  have  proved  fatal  had  it  not  been  for 
the  skill  and  unremitting  attention  bestowed  upon  the  case  by  Dr. 
Kettring. 

Stone  in  the  Bladder;  Lithotrity  by  a  Siagle  Operation.  (N.  A. 
Powell,  M.  D.,  Edgar,  Ontario.)— S.  F.,  aged  now  five  years,  first 
presented  symptoms  of  trouble  referable  to  the  urinary  organs  in 
October,  1S76.  Pain,  partial  incontinence,  and  the  pa-^sage  of 
blood  and  mucus  continued  from  this  time,  and  in  January,  1878,  a 
bit  of  "gravel"  the  size  of  a  split  pea  came  away.  During  the 
following  spring  the  desire  for  urination  became  almost  constant, 
and  vesical  tenesmus  was  marked.  On  June  12th,  my  friend.  Dr. 
Blackstock,  of  Hillsdale,  was  called  to  see  her,  and  on  tho  13tli, 
under  an  anaesthetic,  he  e.camined,  and  found  a  calculus  at  tlie  neck 
of  the  bladder. 

An  operation  for  its  removal  was  advised,  and  pending  this, 
anodynes  were  freely  given.     On  July  9th,  the  writer,  in  cunsulta- 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER.       787 

tion,  saw  the  case  for  the  first  and  only  time.  The  child  was  said 
to  be  failing  very  fast ;  she  was  much  emaciated ;  was  suffering 
severely,  and  seemed  to  gain  a  respite  from  her  pain  only  when 
violently  rocked  while  in  the  knee-chest  f)osition  in  a  cradle.  Pulse 
140,  temperature  102^°  F.  Chloroform,  replaced  later  by  ether,  was 
given,  and  a  stone  found  jammed  into  the  upper  part  of  the  urethra. 
This  was  displaced  upward,  caught  in  the  blades  of  a  smaller  Weiss 
and  Thompson  lithotrite,  and  crushed.  The  scale  showed  five  eighths 
of  an  inch  separation  of  the  blades.  Further  comminution  of  the 
fragments  was  effected  by  means  of  long  polypus  forceps.  Evacua- 
tion was  accomplished  by  the  same,  aided  by  the  frequent  injection 
and  aspiration  of  warm  water  through  a  large-sized  Eustachian 
catheter,  to  which  a  strong  rubber  bulb  had  been  attached.  This 
last  was  the  best  substitute  at  hand  for  Bigelow's  or  Clover's  appa- 
ratus. The  vagina  was  too  small  to  admit  a  linger  without  undue 
stretching,  but  water  could  be  retained  in  the  bladder  by  pressure 
upon  the  urethra. 

The  first  calculus  being  removed,  suprapubic  pressure  brought 
two  other  and  smaller  ones  within  reach,  and  these  were  treated  as 
the  first  had  been.  The  distance  between  the  outer  surfaces  of  the 
blades  of  the  forceps  used  when  grasping  the  largest  fragment  re- 
moved was  three  tenths  of  an  inch;  this,  then,  was  the  limit  of 
urethral  dilatation.  The  lithotrite  was  used  for  crushing  five  times, 
the  forceps  twenty  or  thirty  times.  The  time  occupied  was  one 
liour  and  a  quarter.  The  bladder  being  washed  and  aspirated  till, 
as  nearly  as  possible,  freed  of  its  solid  contents,  the  child  was  put  to 
bed  with  hot  applications  over  the  pubes  and  to  the  extremities,  and 
a  full  anodyne  was  given.  The  detritus  collected  at  the  time  of 
operation  weighed  241  grains ;  subsequently  seven  grains  more 
were  obtained  from  the  strained  urine. 

For  the  history  of  the  case  after  this,  I  am  indebted  to  notes 
kindly  sent  me  by  Dr.  Blackstock  or  his  assistant  Mr.  Gould,  who, 
with  my  students  Messrs.  Shepherd  and  Bremmer,  gave  assistance 
during  the  operation.  "  Partial  control  of  the  urine  returned  on  the 
day  following  the  lithotrity,  and  complete  control,  except  during 
the  night,  after  three  days.  The  desire  to  void  urine  occurred 
about  every  hour  for  several  days,  and  at  the  end  of  a  week,  about 
every  third  hour.  Slight  haematuria  was  noticed  for  two  days." 
Under  date  August  2Tth,  I  hear  that  "the  child's  general  health  is 
good.  She  is  gaining  in  flesh,  and  has  no  symptoms  of  her  former 
trouble." 

The  above  case  would  a  year  ago,  hardly  have  merited  transerip- 


788  DISEASES   OF   WOMEN. 

tion  from  the  case-book  of  a  country  physician  to  the  pages  of  a 
medical  journal.  But  since  the  appearance  of  Dr.  Bigelow's  paper 
on  litholapaxy  *  the  whole  subject  of  the  tolerance  of  the  urinary 
])lad(ler  for  prolonged  instrumentation  has  come  up  for  reconsid- 
eration, and  this  is  offered  in  evidence. 

From  Civiale  down,  all  lithotritists,  so  far  as  the  writer's  knowl- 
edge extends,  have  held  that  the  visits  of  a  lithotrite  to  the  interior 
of  a  bladder  must  be  strictly  limited  in  point  of  time.  Though  ex- 
perts may,  at  times,  have  given  themselves  more  latitude,  they  have 
always  taught  others  not  to  exceed  five  minutes  for  any  one  crush- 
ing. Of  late  years,  also,  the  tendency  has  been  to  confine  the  opera- 
tion within  narrow  and  yet  naore  narrow  limits,  treating  by  it  only 
such  moderate  sized  stones  as  could  be  got  rid  of  in  from  two  to 
four  sittings.  It  remained  for  the  Harvard  professor  to  demonstrate 
that  the  calculus-containing  bladder  of  an  etherized  man  might  be 
manipulated  for  one,  two,  or  more  hours,  and  yet  not  resent  it  by 
cystitis  or  subsequent  atony  ;  provided  that  no  sharp  fragments  were 
left  in  it  to  do  outrage  to  its  lining  membrane.  Although  the  case 
just  given  occurred  in  a  female  child  instead  of  in  an  adult  male,  it 
seems  to  support  Dr.  Bigelow's  conclusions  as  to  vesical  tolerance. 
Surely  the  delicate  tissue  of  a  child's  bladder  is  ill  adapted  for  pro- 
longed contact  with  instruments,  while  the  proportion  of  the  organ 
covered  by  peritonaeum  in  the  child  being  greater  than  in  the  adult, 
there  would  seem  to  be  a  greater  danger  of  serous  inflammation. 
Yet,  here  all  irritation  promptly  subsided  when  the  irritant  was  re- 
moved, although  its  removal  took  one  hour  and  a  quarter.  May 
we  not  expect  like  results  when  even  large  stones  are  crushed  in  the 
male  bladder,  and  evacuated  by  the  new  method  ?  Statistics  so  far 
— seventeen  cases,  sixteen  successful — seem  to  point  that  way. 

It  may  be  asked  why  the  urethra  was  not  more  widely  dilated 
in  this  case  ?  My  answer  is  that  too  large  a  proportion  of  those  thus 
treated  have  been  made  dribblers  for  life  by  it.  The  case  with 
which  stretching  may  be  accomplished,  and  the  free  access  which  it 
gives  to  the  bladder,  will  strongly  tempt  a  surgeon  who  docs  not 
look  beyond  the  operation  he  has  to  do  at  the  future  life  of  his 
patient.  Prof.  Simon,  of  Heidelberg,  made  f  many  accurate  meas- 
urements to  determine  the  extent  to  which  the  adult  female  urethra 
may  be  dilated  without  the  risk  of  incontinence.  His  limit  is  in 
width,  eight  tenths  of  an  inch :  in  circumference,  (1-3  cen.,  (==2*4 
inches).     This  would  allow  a  finger  to  pass,  but  not  a  finger  plus  a 

*  "  American  Journal  of  Medical  Sciences,"  Januan-,  1878. 
f  Translation  in  "New  York  Medifal  Journal,"  October,  1875. 


NON-INFLAMMATORY   DISEASES   OF  THE   BLADDER.       7^9 

pair  of  forceps.  Mr.  J.  R.  Lane  thinks  no  stone  larger  than  an 
acorn  should  be  removed  entire  through  the  urethra  of  an  adult 
female,  and  none  larger  than  a  bean  through  that  of  a  chiid.  Dr. 
Hunter  McGuire,  of  Richmond,  Va.,  states  that  many  cases  of  so- 
called  successful  operations  by  dilatation  and  extraction  have,  to  his 
personal  knowledge,  been  followed  by  incontinence.  Rapid  dilata- 
tion, however,  seems  to  be  less  dangerous  than  slow.  In  jjroof  of 
this,  I  may,  in  conclusion,  mention  that  I  have  knowledge  of  the 
case  of  a  girl,  aged  twelve  years,  into  whose  bladder  a  pair  of 
sequestrum  forceps  was  pushed,  a  calculus  seized  and  extracted 
vi  et  armis^  dilating  and  lacerating  the  urethra  as  it  came.  The 
stone  was  as  large  as  a  pigeon's  egg.  Absolute  incontinence  existed 
for  twelve  days,  but  was  followed  by  recovery. 

Stone  sacculated  in  the  Bladder  of  a  Female.  (By  Charles  Will- 
iams, F.  R.  C.  S.,  Ed.,  Surgeon  to  the  Norfolk  and  Korwich  Hos- 
pital).— Cases  in  which  a  vesical  calculus  is  impacted  in  a  cyst  situated 
in  the  walls  of  the  bladder  are  so  extremely  rare  that  I  consider  it 
a  duty  to  record  this  very  interesting  example : 

A  line,  healthy  girl,  aged  three  years,  living  in  Norwich,  came 
mider  the  care  of  the  late  Mr.  George  Hutchison  in  the  year  1873, 
having  for  several  months  previously  suffered  from  very  decided 
symptoms  of  stone  in  the  bladder.  It  had  been  noticed  by  her 
mother  that  from  the  time  of  her  birth  she  had  experienced  diffi- 
culty, as  well  as  occasionally  severe  pain  in  passing  urine,  and  that 
sometimes  she  voided  blood  mixed  with  it,  and  was  in  the  habit  of 
straining  so  violently  as  to  produce  prolapsus  of  the  rectum. 

On  sounding  the  bladder,  which  was  an  unusually  capacious  one, 
it  was  with  some  difficulty  that  a  calculus  could  be  detected.  At 
the  wish  of  the  parents  Mr.  Hutchison  resolved  to  remove  the  stone 
by  dilatation.  Mr.  W.  H.  Day  assisted  at  the  operation,  and  I  was 
requested  to  administer  chloroform.  The  urethra  was  freely  and 
quickly  dilated  with  Weiss's  trivalve  dilator.  There  was  considera- 
ble trouble  to  find  the  stone,  and  when  found  a  still  greater  trouble 
to  seize  it  with  the  forceps,  (and  it  was  particularly  noticed  that, 
although  the  patient  was  thoroughly  under  the  influence  of  the 
anaesthetic,  the  getting  hold  of  the  stone  with  the  forceps  occasioned 
severe  straining) ;  the  blades  could  not  be  made  to  grip  the  calcu- 
lus ;  they  continually  slipped  off,  bringing  away  pieces  of  the  stone. 
At  last  it  became  absolutely  necessary  to  ascertain  what  occasioned 
the  difficulty.  For  this  purpose  the  urethra  was  still  further  dilated, 
and  the  neck  of  the  bladder  was  also  divided  with  a  probe-pointed 
bistoury.     The  stone  could  now  be  felt  with  the  point  of  the  finger 


790  DISEASES   OF   WOMEN. 

immovably  fixed  in  the  floor  of  the  bladder  on  tlie  patient's  left.  It 
appeared  to  be  of  the  size  of  a  pigeon's  egg,  and  was  inclosed  in  a 
sac,  through  the  neck  of  which  a  small  portion  protruded  into  the 
vesical  cavity,  and  it  was  oflp  this  nodule  that  the  forceps  so  continu- 
ously slipped.  Many  efforts  were  made  to  dislodge  it — first  with  a 
scoop,  then  with  the  fingor,  which  could  barely  reach  it,  and  next 
with  the  forceps ;  they  all  proved  unsuccessful.  Several  portions 
were  broken  off  the  uncovered  portion,  but  the  main  piece  was  left 
in  situ,  as  it  was  considered  undesirable  to  make  any  further  at- 
tempt to  remove  it,  tbe  patient  having  been  a  long  time  under  the 
influence  of  chloroform,  and  apparently  in  a  very  exhausted  con- 
dition. 

The  next  day  the  child  had  voided  very  little  urine.  A  catheter 
was  introduced,  and  a  small  quantity  of  sanguineous  urine  flowed 
out.  She  was  very  drowsy,  and  had  been  so  since  the  operation. 
When  aroused  she  took  milk  and  brandy  very  freely,  but  immedi- 
ately afterward  became  drowsy  again.  She  did  not  appear  to  have 
recovered  from  the  influence  of  the  chloroform.  The  next  day  she 
died.     No  post-mortem  examination  was  permitted. 

I  am  induced  to  believe  that  this  child  died  of  chronic  chloroform- 
poisoning,  and  not  from  the  effects  of  the  oj^eration,  which  was  by 
no  means  roughly  performed,  and  that  there  was  very  little  blood 
lost.  She  never  thoroughly  revived,  but  became  comatose,  and  died 
in  that  condition.  It  is  difficult  to  imasfine  what  could  have  ffiven 
rise  to  the  formation  of  the  sac.  There  never  was  an  obstruction  to 
the  escape  of  the  urine,  such  as  stricture  or  prostatic  enlargement 
might  engender,  for  neither  existed.  We  are  taught  that  a  cyst  is 
usually  formed  by  the  straining  necessary  to  expel  the  urine ;  the 
mucous  membrane  is  forced  between  the  bands  of  muscular  fibers, 
hypertrophied  in  consequence  of  the  strain  to  which  they  are  sub- 
jected. Nothing  of  the  sort  can  apply  in  this  case,  and  it  is  not  easy 
to  believe  that  the  stone  was  the  cause  of  the  cyst,  which  it  might 
have  been,  had  it  been  situated  close  to  the  neck  of  the  bladder. 
When  impacted  in  this  situation,  tlie  very  pressure  to  which  a  stone 
is  subjected  by  the  constant  and  long-continued  action  of  the  bladder 
to  expel  it,  causes  the  mucous  membrane  to  ulcerate  through,  and 
the  stone  is  in  due  time  forced  into  a  cavity,  which  enlarges  as  the 
stone  grows,  and  in  this  way  it  may  form  a  tumor  in  the  vagina.  An 
effort  is  then  made  by  nature  to  contract  the  opening,  which  in  this 
child  was  nearly  accomplished  ;  but  the  calculus  was  far  from  the 
neck  of  the  bladder,  and  could  barely  be  touched  with  the  point  of 
the  finger,  so  that  a  different  explanation  of  the  formation  of  the 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER.       791 

cyst  is  required  ;  and  as  no  examination  was  allowed  to  be  made,  it 
seems  to  me  to  be  almost  impossible  to  suggest  in  what  way  the  sac 
was  formed.  Sabulous  matter,  or  a  few  urinary  crystals,  may  prob- 
ably have  been  deposited  originally  in  a  mucous  follicle,  lacuna,  or 
fossa,  and  gradually  augmented  in  (quantity,  and  in  this  way  the  sac 
inclosing  the  calculus  may  have  been  produced.  The  motiier  of  tlie 
girl  at  four  years  of  age  suifered  from  stone,  whicli  was  removed  by 
the  late  Dr.  Edward  Iiibbock ;  it  was  the  size  and  shape  of  a  wal- 
nut.    She  has  suifered  from  incontinence  since  that  time. 

I  believe  that  it  would  have  been  very  much  better  to  have  re- 
moved tliis  stone  by  cystotomy.  Had  the  patient  lived  she  would 
have  suifered  from  injured  urethra. 

(c)  Foreign  Bodies  introduced  into  the  Bladder  through  the  Urethra. 
— Of  these  it  may  be  truly  said  that  "their  name  is  legion,"  for  in 
the  literature  of  the  subject  we  find  recorded  a  most  numerous  and 
diverse  list  of  objects  found  in  the  bladder  of  the  female.  Some  of 
these  objects  were  forced  into  the  bladder  by  accidents,  such  as  falls 
or  blows  ;  others  were  intentionally  introduced  into  the  urethra  for 
the  purj)Ose  of  masturbation,  and  then  pushed  or  drawn  into  the 
bladder.  The  same  may  occur  in  auto-catheterization,  the  instru- 
ment being  sometimes  broken  off  in  the  bladder,  and  at  others, 
drawn  bodily  into  the  viscus. 

Hysterical  and  foolish  women,  with  or  without  the  intention  of 
masturbating,  have  passed  all  manner  of  things  into  the  bladder,  as 
pins,  needles,  matches,  sand,  charcoal,  bits  of  glass,  bodkins,  and 
tooth-brush  handles. 

Masturbators  have  also  forced  in  various  articles,  such  as  twigs, 
small  wax  candles,  penholders,  nails,  pencils,  and  the  like.  Cathe- 
ters and  clay-pipe  stems,  that  have  been  used  for  purposes  of  cathe- 
terization, have  been  broken  off  and  left  in  the  bladder. 

Pessaries,  which  have  been  badly  fitted,  or  worn  too  long,  have 
passed  l)y  ulceration  from  the  vagina  into  the  bladder. 

8yi)iptor)iatology . — The  symptoms  need  not  be  given  in  detail,  as 
they  are  the  same  as  those  caused  by  any  foreign  body,  usually  aggra- 
vated, however,  if  the  body  be  shai-p  and  have  jagged  edges.  Bleed- 
ing is  not  uncommon,  and  pain  varies  in  amount  and  severity  with 
the  kind,  size,  and  shape  of  the  foreign  body.  Hysterical  women 
have  been  known  to  conceal  the  pain  and  tenesmus  for  a  long  time. 
If  the  bodies  be  small  and  blunt,  they  may  give  rise  to  but  little 
pain  or  tenesmus,  and,  remaining  in  the  bladder  undisturbed,  form 
nuclei  for  calculi.  I  doubt  if  a  modification  of  the  urinary  secretion 
by  reflex  nerve  influence  (excited  by  these  bodies)  is  necessary  to 


792  DISEASES  OF  WOMEN. 

cause  incrustation,  or  form  calculi.      The  hypersecretion  of  mucus 
and  decomposition  of  urine  is  all  that  is  required. 

Treatment. —  The  treatment  of  a  foreign  hody  in  the  bladder  is 
summed  up  in  two  words — remove  it.  This  must  first  he  tried 
through  the  urethra.  A  pair  of  forceps  (those  known  as  the  alli- 
gator forceps  being  the  best)  are  guided  to  the  object,  which  is  to  be 
seized  and  removed.  If  this  is  difficult,  tlie  operation  may  be  done 
through  the  speculum.  If  the  bodies  be  small,  they  may  possibly 
be  washed  out.  If  they  are  so  situated  that  their  removal  by  the 
urethra  is  impossible,  vaginal  cystotomy  may  be  performed,  and  the 
foreign  bodies  thus  removed,  using  such  after  treatment  as  will  re- 
lieve any  cystitis,  which  may  have  been  produced. 


CHAPTEK  XLIV. 

NON-ENTLAMMATOKY  DISEASES  OF  THE  BLADDER    (CONTINUED). 

RUPTURE   OF   THE   BLADDER. 

Rupture  of  the  bladder  may  be  classified  according  to  its  loca- 
tion and  extent,  as  follows  : 

I.  Complete  and  incomplete. 

II.  {a)  Occurring  at  a  point  where  the  bladder  is  covered  with 
peritonaeum. 

(b)  Where  the  bladder  is  not  covered  with  peritonaeum. 

I.  In  the  complete  rupture  all  the  coats  of  the  organ  are  divided, 
while  in  the  incomplete  variety  one  coat  at  least  remains  undivided. 

Pathology. — The  complete  form  of  rupture  is  the  most  common, 
and  the  location  at  which  it  most  frequently  occurs  is  the  posterior 
and  upper  part ;  that  is,  the  part  where  the  walls  of  the  bladder  are 
the  thinnest,  and  probably  where  there  is  the  greatest  exposure  to 
the  causes  of  the  injury. 

There  is  another  reason  given  why  rupture  is  more  frequent 
where  the  bladder  is  covered  with  peritonaeum,  and  that  is  because 
the  peritoneal  covering  is  not  so  elastic  as  the  other  coats. 

When  the  laceration  occurs  within  the  limits  of  the  peritoneal 
coat,  and  is  complete,  the  urine  escapes  into  the  peritoneal  cavity, 
and  produces  shock  and  peritonitis,  which  usually  prove  fatal. 

In  rupture  at  any  point  not  covered  with  peritonaeum,  infiltra- 
tion of  urine  takes  place  in  the  tissues  beneath,  not  within,  the  peri- 
tonaeum. This  infiltration  is  sometimes  very  great,  extending  from 
the  cellular  tissue  of  the  pelvis  to  the  labia  and  thighs. 

The  clinical  history  of  these  two  varieties  diifers  in  its  char- 
acteristics because  of  the  fact  just  mentioned — that  in  the  one  va- 
riety the  urine  escapes  through  the  rapture  into  the  peritoneal  cavity, 
while  in  the  other  the  urine  infiltrates  the  tissues  in  and  about  the 
pelvis. 


T9J:  DISEASES  OF  WOMEN^. 

In  the  one,  peritonitis  is  speedily  developed,  as  a  rule,  and  gen- 
erally proves  fatal ;  in  the  other,  the  progress  is  slower,  and  the 
chief  danger  is  from  septictemia.  There  is  another  class  of  cases 
having  a  pathological  history  which  holds  an  intermediate  position 
between  the  two  already  described. 

In  this  class  the  history  points  to  the  fact  that  the  rupture  has 
been  at  a  point  destitute  of  peritonaeum,  or  else  the  rupture  has  been 
incomplete,  not  involving  the  periton.eum. 

This  gives  rise  to  symptoms  of  severe  internal  injury,  but  less 
severe  than  in  complete  rupture,  which  is  followed  by  a  sudden  giv- 
ing way  and  escape  of  urine  into  the  peritoneal  cavity,  and  subse- 
quent peritonitis.  This  opening  into  the  peritoneal  cavity  at  a  pe- 
riod remote  from  the  injury,  is  due  to  pressure  or  ulceration  or 
sloughing,  which  completes  the  rupture. 

Symptoinatology . — The  symptoms  of  rupture  of  the  bladder  are 
ordinarily  developed  as  follows :  There  is  usually  shock  in  a  mai'ked 
degree,  and  if  the  pelvic  bones  are  broken — a  frequent  complication 
of  this  injury — the  patient  is  unable  to  move  after  having  rallied 
from  the  shock.  Severe  pain  is  felt  in  the  hypogastiic  region,  and 
a  continual  desire  to  urinate,  without  the  power  to  void  tlie  smallest 
quantity  of  urine,  or  possibly  but  a  few  drops  mixed  witli  blood. 
The  constitutional  symptoms  indicate  great  prostration,  which  rapidly 
ensues.  The  patient  has  an  anxious  look,  the  countenance  is  pale, 
the  pulse  feeble  and  fluttering,  respiration  sighing,  skin  clammy  ;  the 
abdomen  in  a  short  time  becomes  tympanitic.  There  is  also  a  rise 
in  temperature  after  a  time,  but  during  the  shock  the  temperature 
may  be  sub-normal ;  delirium,  convulsions,  and  coma  may  occur,  and 
death  may  take  place  in  a  few  hours  in  severe  cases,  or  it  may  be 
delayed  a  few  days.  A  fatal  result  occurs  sooner  in  complete  than 
in  incomplete  rupture. 

If  the  patient  sur\dves  the  shock  or  collapse,  life  may  be  en- 
dangered by  the  development  of  pei-itonitis  or  septic.^mia.  The 
physical  signs  of  rupture  are  few  and  by  no  means  reliable.  I  must 
therefore  give  more  attention  to  the  clinical  history  and  symptoms, 
incidentally  bringing  out  the  only  physical  signs  obtainable,  such  as 
the  empty  state  of  the  bladder  found  when  that  viscus  has  not  been 
emptied  in  several  hours,  and  the  withdrawal  of  a  small  quantity  of 
bloody  urine  by  means  of  the  catheter. 

The  surgeon  is  not  able  to  make  a  certain  diagnosis  in  all  cases, 
as  the  symptoms  are  not  always  pathognomonic.  The  statement  of 
the  patient  that  she  received  a  blow  over  the  hypogastrium,  or  that 
while  in  the  act  of  straining  she  felt  something  give  way,  are  valu- 


NON-INFLAMMATORY  DISEASES  OF  THE  BLADDER.       Y95 

able  as  evidence  when  acute  pain  and  other  symptoms  of  ru])ture 
follow. 

The  evidence  obtained  from  tlie  use  of  the  catheter  is  of  value, 
especially  when  it  is  known  tliat  the  patient  had  not  urinated  for 
several  hours  prior  to  the  accident. 

LTnder  these  circumstances  when  the  bladder  may  contain  a 
small  quantity  of  bloody  urine  or  when  the  bladder  is  empty,  there 
is  strong  evidence  of  the  bladder  being  lacerated.  But  the  evidence 
pointing  to  rapture  is  by  no  means  always  certain.  And  again  very 
often  signs  and  symptoms  whicli  the  diagnostician  depends  upon 
most  are  absent,  and  those  that  are  present  are  liable  to  mislead. 
This  is  very  unfortunate,  but  true.  The  diagnosis  is  especially  ob- 
scure when  there  has  been  a  long  interval  between  the  receipt  of  the 
injury  and  tlie  development  of  characteristic  symptoms.  It  is  there- 
fore necessary  to  watch  a  patient  in  whom  there  is  suspicion  that 
rupture  of  the  bladder  may  have  occurred.  The  symptoms  may  be 
for  a  time  concealed  and  then  develop  rapidly.  The  first  symptoms 
may  be  delayed  or  be  obscure  and  not  attract  attention,  because  the 
vesical  rupture  may  be  involved  with  other  injuries  whose  symp- 
toms for  the  time  hide  the  more  dangerous  lesions.  As  a  rule,  it  is 
rare  to  find  any  external  signs  or  mark  of  injury  on  examination  of 
tbe  abdomen.  When  much  depends  on  the  history  given  by  tbe 
patient  regarding  the  nature  of  the  accident  and  the  condition  of 
the  bladder  at  the  time,  it  frequently  happens  that  she  is  not  able 
to  answer  questions  correctly,  because  of  the  shock  and  the  fact  that 
this  accident  often  occurs  while  the  patient  is  intoxicated. 

Strange  as  it  may  appear,  in  exceptional  cases  the  patient  may 
have  no  difficulty  in  urinating,  and  indeed  may  pass  a  large  quan- 
tity of  water.  Cases  have  been  recorded  where  the  patient  regained 
the  power  of  voluntary  urination  after  the  catheter  was  passed  for 
tiie  first  time. 

Although  it  is  important  to  make  a  diagnosis  early  in  all  cases, 
yet  it  is  of  equal  importance  to  know  whether  the  rupture  is  com- 
plete or  incomplete.  This  can  be  done  by  noting  the  fact  that  in 
the  one  case  tliere  will  be  infiltration  of  the  unue  into  the  cellular 
tissue  of  the  pelvis,  and  in  the  other  such  infiltration  is  absent. 

It  is  often  necessary  to  pass  the  catheter  both  for  diagnosis  and 
treatment,  and  great  care  should  be  taken  in  its  introduction,  for 
sometimes  by  using  too  much  force  it  is  accidently  pushed  through 
the  viscus  into  the  abdominal  cavity. 

Prognosis. — Tlie  chances  of  recovery  are  not  favorable,  espe- 
cially when  the  urine  passes  into  the  peritoneal  cavity  through  a 


796  DISEASES   OF  WOMEN. 

rupture  high  up.  Wlien  the  rupture  is  incomplete  or  does  not  in- 
volve the  peritoneal  coat  and  treatment  is  early  employed,  the  pros- 
pects of  saving  the  life  of  the  patient  are  encouraging. 

Causation. — The  predisposing  causes  of  rupture  are  certain  con- 
ditions of  the  walls  of  the  bladder,  such  as  atrophy,  fatty  degenera- 
tion, ulceration,  and  sacculation  ;  overdistention  from  stricture  or 
other  causes,  and  alcoholic  intoxication  which  favors  overdisten- 
tion, and  exposure  to  the  exciting  causes  of  the  accident.  The 
empty  bladder  may  be  lacerated  in  connection  with  injuries  of  the 
other  pelvic  organs,  but  it  is  a  fact  that  in  the  majority  of  cases  the 
bladder  has  been  less  or  more  distended  at  the  time  of  the  accident. 
It  should  be  borne  in  mind,  however,  that  rupture  has  occurred  a 
great  many  times  when  the  bladder  was  normal  and  not  overdis- 
tended,  there  being  no  predisposing  conditions  present  that  could 
be  recognized.  The  most  common  determining  causes  are  blows 
over  the  region  of  the  bladder.  These  may  be  sustained  in  a 
variety  of  ways,  such  as  direct  blows  or  knocks,  falling  from  a 
height  upon  something  which  violently  strikes  upon  the  hypogas- 
trium.  Rupture  often  occurs  in  connection  with  severe  injuries 
which  fracture  the  pelvic  veins.  In  such  cases  it  is  not  possible  to 
say  whether  the  rupture  occurring  under  such  circumstances  is  due 
to  the  direct  blow  or  to  laceration  by  pieces  of  the  broken  bones. 

Rupture  has  occurred  sufficiently  often  in  the  puerperal  state  to 
warrant  placing  this  condition  in  the  list  of  predisposing  causes. 
One  can  see  how  a  distended  bladder  might  be  ruptured  during 
the  violent  labor -pains  or  the  contortions  of  instrumental  and 
manual  delivery,  and  this  accident  has  occurred  in  that  way.  In 
a  number  of  cases,  however,  the  rupture  has  not  taken  place  un- 
til after  delivery,  showing  that  the  labor  gave  rise  to  retention,  and 
that  to  rupture.  So  far,  then,  as  the  puej*peral  state  is  related  to 
rupture  of  the  bladder  it  may  be  said  that  a  full  bladder  may  be 
ruptured  by  the  direct  violence  done  during  delivery,  but  quite  as 
often  retention  occurs  in  the  puerperal  state,  and  the  rupture  is 
caused  by  overdistention.  In  a  similar  way  rupture  has  occurred 
in  displacement  of  the  uterus  which  caused  retention  of  the  urine. 

The  bladder  has  frequently  been  wounded  during  ovariotomy 
and  hysterectomy  when  there  were  adhesions,  but  this  accident  does 
not  come  under  the  head  of  rupture  now  under  consideration. 

Treatment. — The  first  indications  are  to  relieve  pain  and  shock 
if  either  is  present.  These  objects  can  be  attained  usually  by  opium 
and  stimulants.  If  there  is  infiltration  of  urine  into  the  pelvic 
cellular  tissue  the  urine  should  be  removed  by  punctui'ing  or  incis- 


NON-INFLAMMATORY   DISEASES   OF   THE  BLADDER.       797 

ing  the  parts  atfected.  [Next,  and  most  important  of  all,  the  bladder 
should  be  continuously  kept  empty  by  retaining  the  catheter  in 
the  bladder.  The  catheter  should  be  a  flexible  one  of  soft  rubber 
with  a  perfect  eye  very  near  the  end.  It  should  be  made  to  enter 
the  bladder  only  far  enough  to  secure  perfect  drainage  and  not  far 
enough  to  disturb  the  wound  in  the  bladder.  Yaginal  cystotomy 
has  been  recommended  as  a  means  of  drainage,  but  I  feel  sure  that 
the  catheter  is  a  simpler,  and  certainly  as  reliable  a  means  of  accom- 
plishing the  object.  The  management  of  the  graver  cases,  in  which 
the  rupture  opens  into  the  peritoneal  cavity,  must  be  of  the  most 
heroic  character  in  order  to  be  effectual. 

The  great  object  is  to  cleanse  the  peritoneal  cavity  of  urine  and 
blood.  This  has  been  done  when  the  case  was  seen  early,  by  pass- 
ing the  catheter  into  the  peritoneal  cavity  through  the  rent  in  the 
bladder.  When  this  can  be  done  easily  it  may  answer  that  purpose, 
and  the  patient  may  be  treated  by  rest  and  opium ;  but,  unless  the 
catjieter  passes  without  much  effort  and  the  one  catheterization  is 
sufficient,  this  method  should  not  be  persisted  in. 

Laparotomy  appears  to  offer  the  best  chances  in  these  very  for- 
midable cases.  If  the  patient  is  seen  early,  and  before  extensive 
peritonitis  has  been  established,  I  believe  the  best  that  can  be  done 
is  to  open  the  abdominal  cavity,  and  thoroughly  remove  all  blood 
and  urine  that  have  accumulated.  When  this  has  been  accom- 
plished the  wound  in  the  bladder  should  be  accurately  closed  with 
sutures.  In  case  the  edges  of  the  wound  are  very  irregular,  and 
will  not  fit  together  accurately,  they  should  be  trimmed  suffi- 
ciently to  give  a  clean  and  complete  coaptation.  The  after-treat- 
ment should  then  consist  in  draining  the  bladder,  as  already 
mentioned,  and  managing  the  patient  as  in  laparotomy  for  any 
purpose. 

ILLUSTRATIVE    CASES. 

Case  of  Rupture  of  Female  Bladder  associated  with  Abortion  (by  T. 

Lawrie  Gentles,  L.  F.  P.  S.  G.,  Derby).— On  October  13th  I  was 
requested,  at  3  a.  m.,  to  visit  a  woman  in  a  neighboring  street,  who 
was  said  by  the  messenger  (her  husband)  "  to  have  had  a  mishap." 

On  reaching  the  house  I  found  a  well-made  woman  of  thirty-six 
lying  on  her  left  side  in  bed,  vomiting  large  quantities  of  a  dark- 
brown,  pungent-smelling  liquid.  The  pillows  were  drenched  with 
the  fluid,  so  also  was  the  carpet  in  front  of  the  bed,  and  on  the  walls 
opposite  to  the  patient  were  stains  of  a  similar  nature.  There  was 
also  half  a  pint  of  vomit  in  the  chamber-vessel.     The  woman  was  in 


798  DifciEASES   OF   WOMEN. 

a  state  of  collapse ;  a  cold;  clammy  perspiration  stood  on  her  face, 
her  hands  and  feet  were  like  ice,  and  her  pulse  was  iiiij)er<  e]>tihle. 
There  was  no  one  in  the  house  except  her  husband  and  two  little 
children,  the  latter  occupying  the  same  bed  as  the  patient;  while,  to 
add  still  mure  to  the  ghastliness  of  the  scene,  the  younger  of  the 
children  (a  babe  of  nine  months)  was  vainly  endeavoring  to  reach  its 
dying  mother's  breast  in  order  to  obtain  its  usual  nourishment. 

I  made  a  rapid  examination  by  the  vagina,  but  found  a  closed 
OS  uteri,  and  no  marked  traces  of  hcemorrhage.  I  observed,  however, 
that  the  abdomen  v/as  greatly  distended.  I  tried  to  administer  some 
ammonia,  but  the  patient  was  unable  to  swallow ;  she  gave  me  one 
agonizing  look  of  dread,  moved  her  lips  as  if  t  j  speak,  and  then  died, 
the  death  taking  place  within  a  quarter  of  an  hour  after  my  arrival 
at  the  house. 

My  first  impression  was  that  the  woman  had  died  of  internal 
haemorrhage ;  the  only  things  which  seemed  to  militate  against  tliis 
being  the  redness  of  the  lips  and  the  copious  vomiting.  This  idea 
of  hsemorrhage  seeuied  also  confirmed  by  what  the  husband  said  at 
the  bedside — viz.,  that  "  his  wife  had  had  a  good  many  clots  come 
from  her,  and  that  her  linen  was  very  much  stained." 

I  refused,  of  course,  to  give  any  certificate,  and  communicated 
with  the  coroner.  In  collecting  evidence  for  the  inquest,  the  follow- 
ing facts  were  clearly  brought  out ;  first,  that  the  woman  Avas  a 
drinker ;  secondly,  that  she  had  had  a  drinking-bout  for  some  days ; 
and  thirdly,  that  she  had  had  occasional  difliculty  in  passing  urine. 
In  regard  to  the  first  two  points,  the  husband's  evidence  was  most 
conclusive,  and  showed  clearly  that  vzhe.i  tlie  poor  woman  had  one 
of  her  drinking-fits  on,  she  would  not  only  consume  large  quantities 
of  beer  (her  favorite  drink),  but  also  all  the  spirituous  liquors  she 
could  lay  her  hands  on.  In  regard  to  the  third  point,  the  hus- 
band also  made  clear  the  fact  that  his  wife  had  often  suffered  from 
retention  of  urine,  but,  "so  far,  had  always  got  over  it."  At  the 
inquest,  further  details  of  evidence  brought  to  light  the  fact  that  the 
woman  had  complained  of  pain  in  her  belly  for  two  or  three  days 
previous  to  death.  She  had,  however,  been  "up  and  down  stairs" 
until  1  p.  M.  of  the  day  preceding  her  death ;  but  when  her  husband 
came  home  at  6  p.  m.,  he  found  her  in  great  pain,  and  was  told  by 
his  wife  that  "she  had  been  losing  blood."  A  good  many  clots 
were  in  the  chamber-vessel,  and  these  he  threw  away  into  the  ash- 
pit. The  pain  getting  no  better,  and  finding  that  his  wife  was 
"  altering  for  the  worse,"  he  came  for  a  medical  man  as  already 
stated. 


NON-INFLAMMATORY  DISEASES  OF  THE   BLADDER.       790 

At  tlie  autopsj  there  were  no  external  signs  of  violence  found, 
except  a  slight  abrasion  on  the  forehead,  and  another  on  the  lower 
lip,  and  a  small  bruise  on  the  inner  side  of  the  right  thigh,  none  of 
which  were  of  recent  date.  On  cutting  through  the  abdouiinal  walls, 
the  great  depth  of  fat  and  its  extreme  "  wateriness  "  arrested  our  at- 
tention, the  knife  going  through  the  tissue  with  a  distinct  "swish." 
Suspecting  an  accumulation  of  fluid  in  the  abdominal  cavity,  a  small 
incision  was  made  at  first.  No  sooner  was  this  done  than  a  reddish- 
brown  liquid  began  to  well  up.  Sonae  of  tliis  was  drawn  off,  and  the 
opening  enlarged,  when  nearly  six  pints  of  fluid  were  removed.  The 
stomach  and.  intestines,  having  been  carefully  examined,  were  then 
taken  out,  in  order  to  facilitate  further  search  for  the  lesion.  The 
first  thing  which  we  noticed  was  a  pint  of  blood  lying  in  the  pelvic 
basin  ;  and,  on  making  more  minute  search,  a  rent  was  discovered  in 
the  posterior  wall  of  the  bladder — a  rent  large  enough  to  admit  four 
fingers.  Here,  then,  was  the  cause  of  death.  There  were  some 
fresh  adhesions  on  each  side  of  the  bladder  and  the  pelvic  walls; 
there  were  also  similar  adhesions  between  the  bladder  and  uteiiis. 
All  these  adhesions,  however,  were  extremely  soft,  and  broke  with 
the  slightest  pressure.  The  walls  of  the  bladder  itself  also  seemed 
much  thinner  than  usual.  No  flakes  of  lymph  could  be  discovered 
in  the  fluid  removed  from  the  abdominal  cavity,  and  neither  did 
the  peritonaeum  exhibit  any  great  degree  of  vascularity.  It  may  be, 
however,  I  think,  safely  affirmed  that  a  large  portion  of  the  fluid 
found  was  effused  from  an  irritated  peritonseum,  the  other  portion 
of  the  fluid  being,  of  course,  urine  from  the  ruptured  bladder. 

On  opening  the  uterus,  signs  of  recent  delivery  presented  them- 
selves ;  on  observing  which  I  asked  my  son  to  tell  the  husband  to 
rake  up  "  the  clots  "  from  the  ash-pit.  The  husband  did  so,  and  one 
of  the  "  clots  "  was  found  to  be  a  foetus,  three  inches  in  length. 

Now  comes  the  question :  When  did  the  rupture  of  the  bladder 
occur,  and  had  uterine  action  anything  to  do  with  it  ?  Supposing 
that  the  "pains  in  the  belly,"  of  which  the  woman  complained  for 
two  or  three  days  before  death  were  the  commencement  of  the 
abortion,  it  is  reasonable  to  infer  that,  when  true  expulsive  efforts 
on  the  part  of  the  uterus  began,  these  efforts  would  be  aided  by  the 
action  of  the  abdominal  muscles ;  and,  supposing  still  further,  that 
the  bladder  was  at  that  time  distended  to  its  fullest  cajjacity,  it  is 
perfectly  possible  that  the  pressure  of  the  al)dominal  muscles  would 
be  the  "last  straw"  necessary  to  produce  the  fatal  lesion,  I  am, 
therefore,  inclined  to  think  that  the  rupture  took  place  in  the  after- 
noon of  the  12th,     I  ought  to  have  stated  that,  although,  when  the 


8uO  DISEASES   OF   WOMEX. 

husband  came  lioine  at  6  p.  m.  on  that  day  he  found  his  wife  in  bed, 
she,  nevertheless,  "  kept  getting  out  of  bed,  trying  to  pass  urine,  but 
could  not."  There  can  be  little  doubt  that  the  alcoholic  condition 
of  the  patient  would  rob  her  of  her  sense  of  attending  to  the  calls  of 
nature;  and  it  is  mL4ancholy  to  think  that,  if  she  had  only  been  seen 
earlier,  a  simple  catheterism  might  have  saved  her. 

As  a  piece  of  concurrent  evidence  of  the  habits  of  the  patient,  it 
maybe  stated  that  the  liver  was  a  genuine  "nutmeg";  that  the 
kidneys  were  thoroughly  disorganized  (the  cortical  substance  being 
rarely  distinguishable) ;  and  that  the  spleen  was  exceedingly  soft. 
The  heart  was  small  and  fatty.  The  lungs  were  fairly  healthy,  but 
there  were  extsnsive  adhesions  in  the  right  pleural  cavity.  The 
head  was  not  examined. — British  Medical  Journal^  January  6', 
1883. 

Cases  of  Rupture  treated  by  Laparotomy. — (A.  G.  Walter.) — Ten 
hours  after  a  severe  injury,  no  urine  was  found  by  the  catheter.  The 
abdomen  was  opened  in  the  linea  alba  by  an  incision  beginning  one 
inch  below  the  umbilicus  and  terminating  one  inch  above  the  pubes, 
to  the  extent  of  six  inches.  The  intestines  were  found  inflated, 
their  peritoneal  coat,  as  well  as  that  hning  the  interior  of  the  ab- 
dominal walls,  already  showing  evident  marks  of  congestion.  A 
soft  sponge  was  then  cautiously  introduced  into  the  abdomen,  with 
which  the  extravasated  fluid,  consisting  of  urine  and  blood,  was 
carefully  removed  from  the  pelvis  and  between  the  convolutions  of 
the  bowels,  amounting  to  nearly  a  pint.  A  rent  was  found  at  the 
fundus  of  the  bladder,  two  inches  in  extent.  The  cavity  of  the  ab- 
domen being  cleansed  of  the  noxious  agent,  the  wound  of  the  blad- 
der was  left  to  itself,  as  no  urine  was  seen  to  escape  from  it.  The 
abdominal  wound  was  closed  by  strong  Carlsbad  needles,  secured  by 
silver  wire  (only  skin  and  fascia  being  stitched,  while  the  peritonaeum 
was  left  untouched);  a  flannel  bandage  encircled  the  whole  abdomen. 
The  patient,  awakening  from  the  anaesthetic  sleep,  felt  relieved  of 
pain  and  the  desire  to  urinate,  so  distressing  before  the  operation ; 
vomiting  did  not  return  ;  opium  in  one-grain  doses  was  ordered ; 
abstinence  of  drink  and  perfect  quietude  of  body,  with  retention  of 
the  catheter,  were  strictly  insisted  upon.  He  soon  began  to  doze, 
had  a  comfortable  night,  was  free  from  pain  the  next  morning,  com- 
plaining only  of  soreness  in  the  abdomen,  without  tympanites,  sick- 
ness, or  calls  to  urinate ;  thirst  less  urgent.  The  treatment  being 
vigorously  continued,  for  drinks  iced  barley-water,  water  only  in 
very  small  quantities,  with  pieces  of  ice,  being  allowed.  Xo  un- 
pleasant symptom  followed ;  urine  in  small  quantities,  but  free  of 


NON-INFLAMMATORY  DISEASES  OF  THE   BLADDER.       801 

the  admixture  of  blood,  passing  by  the  catheter.  On  the  third  day 
the  intervals  between  the  doses  of  opium  were  lengthened  to  two 
hours;  on  the  fifth,  to  three,  and  thus  gradually  decreased  as  all  signs 
of  inflammation  had  passed.  At  the  end  of  a  week  the  abdominal 
wound  appeared  to  be  closed  by  iirst  intention  ;  the  stitches,  however, 
were  not  removed  till  a  week  later.  The  gum-elastic  catheter  was 
replaced  by  a  new  one  every  two  days,  and  was  not  withdrawn  for 
two  weeks  after  the  injury  had  been  received,  and  then  only  for  a 
short  time.  At  the  expiration  of  two  weeks,  with  the  absence  of  all 
pain  and  tenderness,  opium  was  omitted.  The  intestines  were  re- 
lieved by  warm-water  injections  on  the  tenth  day,  when  mild  nour- 
ishment was  ordered.  Between  the  second  and  third  week  the 
catheter  was  permanently  withdrawn,  and  only  introduced  every 
four  hours  for  the  evacuation  of  urine.  After  the  third  week,  the 
patient  left  his  bed.  He  has  remained  well,  working  at  his  trade, 
and  feeling  no  impediment  in  his  urinary  organs. 

(Alfred  Willett). — An  incision  some  Ave  to  six  inches  in  length, 
from  the  umbilicus  to  the  pubes,  was  made  in  the  mesial  line  and 
carried  through  the  parietes.  All  bleeding  points  having  been  se- 
cured, the  peritonaeum  was  opened,  and  at  once  several  ounces  of 
dull,  brownish  fluid,  with  strong  urinous  odor,  escaped.  The  intes- 
tines were  greatly  distended,  and  instantly  bulged  out  through  the 
wound.  The  peritonaeum  generally  was  highly  injected,  and  adja- 
cent surfaces  were  glued  together.  Passing  my  hand  into  the  pelvis 
I  detected  a  laceration  of  the  bladder.  The  coils  of  gut  were  only 
slightly  more  adherent  here  than  in  the  abdomen  proper  ;  I  satis- 
fied myself  that  there  was  no  protrusion  of  bowel  into  the  lacerated 
bladder.  The  omentum  was  raised  from  off  the  intestines,  and  so 
much  of  the  latter  as  lay  in  the  pelvis  was  drawn  up,  laid  upon  the 
upper  part  of  the  patient's  abdomen,  and  protected  from  harm  and 
chill  by  flannels  wrung  out  of  moderately  hot  water.  There  was 
about  half  a  pint  of  bloody,  urinous  fluid  in  the  pelvis,  and  when 
this  had  been  sponged  away,  a  rent  of  the  bladder  some  three  and  one 
half  inches  in  extent  was  exposed.  It  extended  diagonally  across  the 
fundus,  having  a  direction  from  before  backward  and  from  right  to  left. 
The  appearance  was  that  of  a  nearly  straight  tear  through  all  the 
coats  of  the  bladder,  except  at  its  most  dependent  parts,  where  it  was 
jagged  and  uneven.  The  bladder  was  flaccid,  but,  of  course,  quite 
empty,  and  at  the  site  of  rupture  its  walls  were  fully  half  an  inch  in 
thickness.  I  brought  the  toi'n  edges  easily  in  apposition,  and  united 
them  by  eight  interrupted  sutures  of  fine  Chinese  silk.  The  sutures 
were  placed  at  intervals  of  rather  less  than  half  an  inch,  and  seemed 
52 


802  DISEASES   OF   WOMEN. 

to  close  the  rent  completely.  Before  returning  the  intestines  I 
cleaned  out  the  abdomen  as  thoroughly  as  I  was  able ;  but  the  mes- 
entery of  the  gut  lying  outside  the  abdomen  acted  as  a  transverse 
diaphragm,  and  I  was  disappointed  to  find  on  replacing  these  coils 
that  some  of  the  fluid  had  been  pent  up  above  it.  Owing  to  gaseous 
distention,  very  considerable  difficulty  was  experienced  in  rei)]acing 
all  the  intestines  ^vithin  the  abdomen,  and  I  was  quite  unable  to  in- 
troduce my  hand  and  cleanse  the  upper  part  of  the  peritoneal  cavity 
as  satisfactorily  as  I  could  have  wished  ;  but  the  patient's  shoulders 
were  raised  in  order  to  make  the  pelvis  more  dependent,  and  all  fluid 
that  found  its  way  there  was  removed.  The  intestines  that  had  been 
lying  out  of  the  abdomen  during  the  operation  were  sponged  over 
with  warm  water  and  carefully  cleansed  before  returning  them.  So 
extreme  was  their  distention  that  to  enable  me  to  introduce  sutures, 
and  close  the  external  wound,  Mr.  Langton,  who  assisted  me,  was 
obliged  to  spread  out  his  hand  and  restrain  the  bowels  from  forcing 
their  way  through  the  wound,  withdrawing  his  hand  gradually  as  the 
successive  sutures,  also  of  Chinese  silk,  were  tightened.  Through 
the  lower  angle  of  the  abdominal  wound  I  passed  a  carbolized  drain- 
age-tube into  the  pelvis,  securing  it  to  the  edge  of  the  external 
wound,  which  was  then  dressed  precisely  as  after  ovariotomy.  A 
Thompson's  catheter  was  introduced  and  retained  in  the  bladder.  On 
being  replaced  in  bed,  hot  bottles  were  placed  beside  the  patient,  and 
he  was  well  covered  up.  The  wound  in  the  abdominal  parietes  was 
found  on  the  autopsy  to  be  adherent  almost  along  its  whole  line ;  not 
much  swelling  of  abdomen.  The  intestines  immediately  behind  the 
wound  were  adherent  to  it.  All  the  coils  of  intestine  in  the  lower  half 
of  the  abdomen  were  adherent  to  each  other  and  to  the  abdominal 
walls  by  recent  lymph.  The  intestines  in  contact  with  the  bladder 
were  adherent  to  it.  There  were  about  two  ounces  of  bloody  fluid  at 
the  back  of  the  peritoneal  cavity ;  about  an  ounce  of  this  lay  just 
above  the  bladder.  The  opening  in  the  bladder  was  everywhere  well 
closed,  except  between  the  posterior  two  stitches,  where  there  was  an 
orifice  through  which  water  injected  per  urethram  escaped  very  freely. 
Even  here  there  appeared  to  be  an  attempt  at  repair.  Elsewhere  the 
edges  of  the  wound  were  adherent.  There  was  very  little  sign  of 
inflammation  in  the  interior  of  the  viscus. 

(Christopher  Heath). — Man,  aged  forty-seven.  Pubes  being 
shaved  and  washed  with  carbolic  lotion,  an  incision  was  made  in  the 
middle  line  just  above  the  pubes  for  two  inches,  and  the  tissues 
divided  down  to  the  peritonaeum,  which  appeared  blue,  the  recti  mus- 
cles, which  were  firmly  contracted,  being  held  aside  by  retractors 


NON-INFLAMMxiTOKY   DISEASES   OF   THE   BLADDER.       803 

with  difficulty.  The  peritonaeum  was  then  picked  up  and  a  cut  made 
into  it,  when  a  gush  of  tiuid,  hke  that  drawn  off  by  the  catheter, 
came  out.  A  large  quantity  of  clots  was  then  taken  out  from  the 
peritoneal  cavity.  The  finger  introduced  into  the  peritoneal  cavity 
found  a  long  rent  in  the  posterior  wall  of  the  bladder  high  up.  This 
was  sewed  up  by  a  continuous  catgut  suture  firmly  tied  at  both  ends. 
The  clots  were  removed  as  far  as  possible  from  the  peritonaeum,  and 
the  cavity  sponged  out  after  injection  with  warm  water,  and  a  long 
large-sized  drainage-tube  was  inserted  at  the  lower  angle  of  the 
wound,  the  upper  part  of  the  wound  being  brought  together  by  deep 
and  superficial  sutures.  A  catheter  was  passed  into  the  bladder,  to 
which  was  afterward  attached  some  India-rubber  tubing  leading  into 
a  vessel  under  the  bed.  Hot  poultices  were  applied  to  the  al)douien, 
and  one  grain  of  opium  was  administered  every  four  hours.  Tlie  fur- 
ther history  shows  great  relief  and  improvement,  but  on  the  fourth 
day  after  the  operation  the  patient  became  rapidly  worse  and  died. 
Autopsy. — Small  intestines  considerably  distended.  For  two  inches 
around  the  abdominal  wound  the  intestines  were  adherent  by  recent 
lymph  to  each  other,  and  to  the  abdominal  parietes.  Above  and  on 
each  side  of  these  adhesions  there  was  no  trace  of  peritonitis.  On 
tearing  away  these  adhesions  some  coils  of  intestines' were  seen  lying 
over  the  pelvis  glued  together,  and  to  adjacent  parts  by  recent  blood- 
stained lymph.  On  lifting  these  coils  upward,  the  recto-vesical 
pouch  of  peritonaeum  was  exposed,  containing  about  six  ounces  of 
clotted  blood,  black  in  color,  and  moderately  offensive  odor.  There 
was  a  rent  in  the  mid  line  of  the  posterior  wall  of  the  bladder  two 
inches  in  length,  extending  upward  as  high  as  the  apex.  The  lower 
third  of  the  rent  was  gaping ;  the  edges  of  the  rest  were  approxi- 
mated by  the  catgut  suture,  the  lower  end  of  which  was  free  and 
loose. 


CHAPTEE  XLY. 

NON-INFLAMMATOEY   DISEASES    OF    THE   BLADDER    (CONTINUED). 
NEOPLASMS,  HYPERPLASIA,  ATROPHY. 

Owing  to  the  very  imperfect  facilities  for  observing  the  internal 
surface  of  the  bladder  during  life,  the  study  of  vesical  neoplasms 
up  to  within  a  few  years  was  chiefly  post-mortem,  and  of  course 
their  therapeutics  was  almost  nil.  At  the  present  time,  however, 
by  means  of  the  endoscope,  the  microscope,  and  the  operation  of 
cystotomy,  more  accurate  methods  of  diagnosis  and  of  rational  and 
successful  treatment  have  been  developed. 

The  neoplasms  of  the  bladder  may  be  classified  as  follows  : 

Benign. — Myxoma,  fibroma,  myoma,  myofibroma,  tubercle. 

Malignant. — Epithelioma,  encephaloid,  scirrhus,  sarcoma. 

Tumors  of  the  bladder  and  deposits  in  its  walls  are  by  no  means 
common,  and  those  of  a  benign  nature  are  less  common  than  those 
that  are  malignant.  There  has  been  some  dispute  as  to  whether 
some  of  these  neoplasms  are  malignant.  This  is  especially  the 
case  in  regard  to  the  villous  growth,  the  German  and  some 
English  authorities  ranking  them  as  essentially  malignant,  while 
some  American  authors,  as  Yan  Buren  and  Keyes,  deny  in  toto  that 
they  have  any  such  property.  More  will  be  said  of  this  when  I 
come  to  the  class  in  which  I  have  placed  them  ;  not  that  I  am  satis- 
fied that  they  are  malignant,  but  for  lack  of  positive  evidence  of  the 
new  idea,  temporarily  at  least,  I  adhere  to  the  old  one. 

Benign  Growths. — Myxomata,  Mucous  Polypi,  and  Polypoid  Hy- 
pertrophies, while  having  nearly  the  same  anatomical  characters,  are 
really  different  affections  as  regards  etiology,  symptomatology,  prog- 
nosis, and  treatment. 

Mucous  polypi  are  isolated  hypertrophies  of  the  mucous  mem- 
brane, varying  in  size,  and  giving  rise  to  trouble  only  in  proportion 
to  their  size.  They  may  exist  at  birth,  or  be  develo]3ed  at  any  time 
during  life,  being  more  common,  however,  in  youth  and  middle 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER.       805 

age.  The  mucous  membrane  covering  them  is  thickened  and  pulpy, 
and  that  about  their  base  and  in  their  immediate  neighborhood  is 
somewhat  thickened,  and  more  vascular  than  normal.  If  the  polypi 
are  situated  at  or  near  the  neck,  or  in  other  portions  of  tlie  bladder, 
where  their  long,  narrow  pedicles  admit  of  a  blocking  of  the  urethra, 
the  entire  mucous  membrane  of  the  organ  suffers,  as  in  all  cases  of 
retention  and  decomposition  of  urine.  If  the  obstruction  is  great, 
and  the  organ  requires  spasmodic  and  irregular  muscular  effort  to 
empty  it,  there  will  be,  sooner  or  later,  not  only  cystitis,  but  mus- 
cular as  well  as  mucous  hypertrophy. 

These  growths  may  be  as  small  as  the  head  of  a  pin,  or  as  large  as  a 
goose-egg ;  they  consist  of  hypertrophied  and  hyperplastic  connective 
tissue,  covered  by  soft,  pulpy,  hyperplastic  mucous  membrane,  that 
bleeds  easily  on  touch.  They  may  coexist  with  uterine  fibroids. 
Their  favorite  seat  is  the  posterior  wall  of  the  bladder. 

General  polypoid  hypertrophy  of  the  mucous  membrane  con- 
sists in  an  irregular  thickening  of  the  mucous  membrane  through- 
out, accompanied  as  a  rule  by  hypertrophy  of  the  muscular  and 
serous  coats.  There  is  an  increased  blood-supply,  the  membrane  be- 
ing bright  red  in  color,  the  capillaries  dilated,  and  the  whole  mass 
bleeding  easily  on  the  touch.  It  has  somewhat  the  appearance  of 
fresh  granulations.  Upon  the  free  surface  of  the  mucous  membrane, 
.there  is,  as  we  should  expect,  an  excessive  cell  proliferation,  these 
cells  being  in  a  transitional  condition,  i.  e.,  occupying  the  position 
between  imperfect  and  perfect,  and  not  all  of  the  same  degree  of 
perfection  or  imperfection  of  development.  There  may  be  either 
serous  or  gelatinous  infiltration,  giving  it  a  heavy,  sodden  look. 
Upon  the  surface  are  often  found  incrustations  of  the  urinary  salts. 

It  appears  to  me  that  there  has  been  an  undue  complexity  of 
classification  of  this  subject,  especially  among  the  German  patho- 
logists, some  of  whose  differences  are  too  minute  to  be  of  any  prac- 
tical value  from  either  a  pathological,  diagnostic,  or  remedial  point  of 
view.  Tumors  which  they  call  villous  or  papilloma  vesicEe  are,  in 
many,  if  not  all  respects,  idontical  with  the  so-called  polypoid  hyper- 
trophy of  the  vesical  mucous  membrane.  For  all  practical  purposes 
they  are  essentially  the  same. 

They  have  been  described  as  enlarged  papillae,  the  vessels  of 
which  are  dilated,  and  their  walls  thinned.  They  only  differ  from 
the  polypoid  hypertrophy  in  increase  of  vascularity,  and  the  fact 
that  they  are  u^ially  limited  to  the  trigone.  Underlying  and  about 
them  is  a  thin,  wavy  stroma  of  connective  tissue,  that  becomes  in- 
creased as  the  disease  advances. 


806  DISEASES   OF  WOMEN. 

The  surface  of  these  growths  varies  very  much  in  different  cases ; 
in  some  looking  like  large  granulations,  in  others  having  more  body, 
being  more  compact,  and  looking  sumewhat  like  a  raspberry  or  mul- 
berry. Occasionally,  they  are  slightly  pedunculated.  Their  surface 
has  an  epithelium  resembling  the  superficial  layer  of  the  bladder, 
unless  proliferation  is  veiy  rapid,  when  the  cells  lose  their  identity, 
and  take  a  multiplicity  of  forms,  to  which  may  be  attributed,  perhaps, 
their  having  sometimes  been  mistaken  for  cancer  cells  when  found 
in  the  urine.  Fatty  degeneration  of  the  most  superticial  cells  is  by 
no  means  uncommon.  As  the  villi  increase  in  size  and  number,  the 
connective-tissue  stroma,  while  increasing  about  their  base,  dimin- 
ishes in  the  prolongations  themselves,  leaving  little  besides  a  mass 
of  tortuous,  thin-walled,  dilated  vessels  hanging  free  in  the  Ijladder. 
The  rest  of  the  mucous  membrane  is  usually  soft  and  hyperplastic, 
and,  if  there  be  any  stoj^page  to  the  free  outflow  of  urine,  inflamma- 
tion may  coexist,  with  incrustations,  and  possibly  dilatation  of  the 
ureters.     The  muscular  coat  is  also  usually  slightly  hypertrophied. 

Fibroid  tumors  and  myo-fibromata  are  very  rarely  found  in  the 
bladder.  When  they  do  exist  they  have  all  the  characters  of  the 
libroina  or  myo-fibroma  found  elsewhere,  and  give  rise  to  the  same 
changes  in  the  vesical  walls  and  ureters  that  other  tumors  do,  viz., 
retention  with  liypertrophy,  or  dilatation,  cystitis,  and  inflammation 
of  the  ureter.  They  may  have  their  seat  in  any  part  of  the  l)Iadder- 
wall,  and  occur  at  any  period  of  life. 

Syrnjytomatology. — The  symptoms  of  vesical  neoplasms  are  di- 
visible into  local  and  constitutional ;  the  former  being  by  far  the 
more  important.  The  local  symptoms,  if  the  tumors  be  of  any  size, 
are  those  produced  by  a  foreign  body  in  the  organ,  viz.,  irritation, 
and  sooner  or  later  inflammation. 

Obstraction  to  urination  sometimes  occurs  when  the  tumors  are 
in  a  position  to  block  the  urethra,  and  by  the  sloughing  off  or  de- 
tachment of  small  fragments,  which  may  or  may  not  be  incrusted. 
These  are  forced  into  the  urethra,  and  obstruct  the  outflow  of 
urine. 

Pain  in  one  form  or  another  is  almost  always  present.  It  may 
consist  of  a  simjDle  uneasiness  in  the  hypogastric  region,  or  amount 
to  actual  pain.  It  may  have  its  seat  in  the  hypogastric  region  in  the 
perinEeum,  or  more  rarely  at  the  end  of  the  urethra.  It  may  also  be 
felt  in  the  loins,  or  along  the  thigh  and  knee.  It  is  usually  more 
intense,  as  all  the  symptoms  are,  during  the  menstrual  flow.  This 
is  not  so  in  all  cases. 

Frequent  urination  and  vesical  tenesmus  are  as  a  rule  present, 


NON-INFLAMMATORY   DISEASES   OF   THE   BLADDER.       807 

but  are  not  proportionate  to  the  size  of  the  tumor,  a  very  small  neo- 
plasm often  giving  rise  to  most  intense  spasm. 

Haemorrhage  is  by  no  means  infrequent,  and  in  some  cases  is 
very  severe  and  not  readily  checked  ;  in  others  it  is  slight,  simjjly 
tinging  the  urine  or  imparting  to  it  a  smoky  appearance,  that  is 
characteristic  of  the  presence  of  a  small  amount  of  blood  or  blood- 
coloring  matter  in  acid  urine.  When  the  haemorrhage  is  extensive, 
and  the  bladder  is  distended  by  the  fluid  or  clotted  blood,  retention 
of  urine  is  apt  to  occur,  and  sometimes  obstructive  suppression,  that 
may  lead  to  most  serious  results. 

Hgematuria  is  as  liable  to  occur  with  the  benign  as  with  the  ma- 
lignant growths,  and  consequently  is  of  little  value  in  differential 
diagnosis.  The  effects  of  prolonged  or  repeated  hsiemorrhage  upon 
the  constitution  are  often  most  serious,  and  the  patients  are  apt  to 
be  anfemic  and  also  cachectic  in  appearance.  I  have  had  one  case  in 
which  haemorrhage  was  the  only  symptom  present. 

The  presence  of  the  foreign  body  in  the  organ  soon  gives  rise  to 
inflammation,  which  is  seriously  aggravated  if  retention  accompany 
it.  The  urine  is  then  found  loaded  with  mucus,  muco-purulent  or 
purulent  matter,  epithelial  scales,  tissue  shreds,  bits  of  tumor,  and 
the  triple  and  amorphous  phosphates. 

Intense  and  repeated  vesical  tenesmus  aggravates  the  inflamed 
condition  of  the  membrane,  and  after  a  time  leads  to  muscular  hyper- 
trophy and  increased  haemorrhage. 

In  these  cases,  as  in  cystitis  from  any  other  cause,  dilatation  of 
the  ureters,  with  a  traveling  upward  of  the  inflammation  and  destruc- 
tion of  the  kidney,  may  result.  This  dilatation  and  the  evil  after- 
results  are  more  apt  to  occur  if  the  neoplasm  be  of  sufficient  size  to 
obstruct  the  free  outflow  of  urine,  as  at  every  spasmodic  and  forcible 
contraction  of  the  hypertrophied  organ  some  urine  is  dammed  back 
in  the  ureters,  dilating  them  gradually.  When  the  ureteric  openings 
are  dilated,  so  that  urine  regurgitates  at  each  vesical  contraction, 
serious  lesions  result,  as  ureteritis,  pyonephrosis,  renal  abscess,  or,  if 
the  process  be  &low,  gradual  renal  atrophy,  uraemia,  and  finally 
death. 

The  general  system  may  or  may  not  suffer  severely  for  a  long 
time.  In  most  cases  it  does.  The  usual  train  of  symptoms,  such  as 
loss  of  sleep,  disorder  of  digestion,  sweating,  and  blood  contamina- 
tion are  developed  in  regular  sequence.  The  patients  become  thin, 
and  have  a  worn,  anxious  expression,  and,  as  I  have  already  said,  are 
apt  to  be  both  anaemic  and  cachectic. 

If  renal  troubles  complicate  this  affection,  casts,  renal  cells,  and 


808  DISEASES  OF  AVOMEN. 

albumen  may  appear  in  the  urine.  In  renal  abscess-atrophy,  or  pyo- 
nephrosis, however,  the  urine  may  be  examined  for  weeks  without 
showing  any  renal  tissue,  casts,  or  epithelium,  there  being  simply  an 
abundance  of  pus. 

DiafjuosU. — The  diagnosis  of  vesical  neoplasms  is  made  cliiefly 
by  physical  signs.  The  methods  employed  in  their  investigation 
may  be  arranged  under  two  heads. 

Direct. — Bimanual  touch,  speculum,  endoscope,  curette,  catheter, 
palpation. 

Indirect. — Uri  ne. 

Direct. — An  intelligent  employment  of  the  methods  classed  under 
the  first  head  is  all  that  is  necessary  to  make  a  clear  diagnosis  in 
some  cases.  The  bimanual  touch  will  i-eveal  the  presence  of  the 
tumor,  if  it  is  of  any  great  size,  and  also  its  size  and  fixation  in  one 
place.  This  fixed  position  is  of  much  importance  as  distinguishing 
a  neoplasm  from  other  foreign  bodies,  stone,  for  example,  which  is 
movable,  and  can  be  pushed  from  one  side  of  the  bladder  to  the 
other.  The  use  of  the  endoscope  will  show  at  once  the  appearance 
of  the  tumor,  if  it  is  favorably  located,  and  by  scraping  away  a  little 
with  the  curette  (through  the  siDeculum),  its  nature  may  be  discov- 
ered by  a  microscopical  examination. 

The  use  of  the  catheter  or  finger  in  the  bladder,  or  one  in  the 
bladder  and  the  other  in  the  vagina,  may  be  resorted  to  in  cases 
where  the  diagnosis  is  difficult.  But  these  are  extremely  painful 
manipulations,  are  not  free  from  danger,  and,  consequently,  should 
not  be  resorted  to  unless  there  is  failure  by  other  means. 

Indirect. — An  examination  of  the  urine  in  these  cases  will  lead 
to  the  suspicion  of  the  presence  of  some  neoplasm  in  the  bladder, 
from  the  occurrence  of  tissue  shreds  and  bits  of  the  tumor  in  this 
fluid.  A  piece  of  tumor  will  sometimes  become  detached  and  be 
expelled  with  the  urine,  and  by  careful  searching  it  may  be  found. 
This  can  be  placed  under  the  microscope,  and  thus  the  examiner 
may  be  able  to  tell  exactly  what  kind  of  a  growth  exists. 

Prognosis. — With  our  jiresent  means  for  exploring  and  operat- 
ing upon  the  inside  of  the  female  bladder,  the  prognosis  of  benign 
neoplasms  is  very  good,  if  the  operation  for  removal  be  performed 
early  enough  in  the  disease.  Operation,  however,  at  any  time  gives 
promise  of  good  result. 

There  is  danger  of  relapse,  as  we  learn  from  the  cases  of  Simon, 
Hutchinson,  and  others.  If  the  operation  be  carefully  done,  even 
incontinence  of  urine  may  be  avoided,  and  complete,  and  permanent 
recovery  follow.     Without  operation  patients  have  lived  as  long  as 


NON-INFLAMMATORY  DISEASES   OF  THE   BLADDER.       809 

nineteen  years,  in  some  cases  suffei'ing  but  little ;  and  it  may  be 
well  to  say  that  not  all  of  these  cases  are  accompanied  by  cystitis,  a 
little  pus  and  blood  in  the  unne  at  intervals,  with  occasional  frag- 
ments of  tumor,  being  all  that  is  found. 

Causation. — The  causes  of  these  neoplasms  are  veiy  obscure,  in- 
deed, no  definite  facts  can  be  adduced  in  favor  of  any  of  the  causes 
given  by  the  various  authors.  Some  speak  of  them  as  due  to  the 
irritation  of  calculi,  calculous  fragments,  and  incnistations.  These, 
however,  may  be  readily  secondary  to  and  produced  by  the  neo- 
plasm, being  the  effect  rather  than  the  cause.  Moreover,  it  is 
known  that  while  persons  carrying  foreign  bodies  of  various  kinds  in 
the  bladder  for  a  length  of  time,  are  very  apt  to  have  cystitis,  neo- 
plasms are  seldom  found,  and  are  very  rare  under  any  circumstances. 

Some  authors  look,  with  a  show  of  reason,  I  think,  to  the  irrita- 
tion from  blood  transudations  into  the  bladder-walls,  as  a  cause. 
This  is  borne  out  by  two  well-authenticated  cases  occurring,  one  in 
the  practice  of  Plutchinson,  of  England,  the  other  in  that  of  Winckel, 
of  Germany.  The  etiology  of  these  neoplasms  needs  further  care- 
ful study,  before  any  cause  or  causes  can  be  pronounced  upon  with 
certainty.  The  free  and  intelligent  use  of  the  modern  means  of 
physical  exploration  in  all  affections  of  the  female  bladder  will  in  a 
few  years  throw  much  light  upon  this  subject. 

Treatment. — There  is  really  but  one  form  of  treatment  for 
these  benign  neoplasms,  viz.,  removal.  The  method  will  differ 
with  the  size  of  the  growth.  If  the  tumor  be  not  of  large  size,  it 
may  be  seen,  reached,  and  removed  through  the  urethra.  This  may 
be  accomplished  by  twisting  it  off  by  means  of  a  pair  of  forceps, 
ligating  its  pedicle,  and  allowing  it  to  slough  off  or  by  passing  the 
wire  of  the  galvano-cautery  around  it.  If  the  pedicle  be  not  sutM- 
ciently  distinct,  or  the  mass  too  soft  to  come  away  in  mass,  it  may 
be  broken  down  and  removed  in  pieces,  either  by  the  linger  and  for- 
ceps, or  by  the  curette  and  forceps.  The  haemorrhage,  which  as  a 
rule  is  not  great,  may  be  controlled  by  injections  of  iced  water,  ice 
to  the  pubes,  and  sometimes  by  tamponing  the  vagina.  Some  oper- 
ators have  found  it  necessary  to  apply  directly  to  the  bleeding  sur- 
face the  liquor  ferri  sesqui-chloridi  (Braxton  Hicks). 

The  after  treatment  consists  in  washing  out  the  organ  thoroughly 
yet  carefully  with  warm  water  to  which  may  be  added  salicylic  acid 
(1  part  to  60).  The  pain  may  be  controlled  by  opium,  either  by 
the  mouth  or  rectum.  The  urine  should  be  kept  slightly  alkaline, 
and  under  no  circumstances  allowed  to  remain  in  the  bladder  long 
enough  to  decompose  and  irritate  or  overdisteud  it. 


810  DISEASES  OF  WOMEN. 

If  the  tiinior  is  too  large  to  admit  of  removal  ])er  urethram  Si- 
mon's operation  should  be  resorted  to.  Also  in  cases  where  the  tumor 
is  so  situated  as  to  be  beyond  the  operator's  reach  through  the  ure- 
thra. I  have  already  fully  described  this  operation.  A  T-incision 
is  made  into  the  anterior  vaginal  wall,  the  bladder  opened,  inverted 
through  the  opening,  and  the  tumor  is  thus  brought  into  easy  posi- 
tion for  any  operative  procedure.  When  removed,  its  base  may  be 
cauterized,  and  the  bladder  replaced.  "When  the  surface  has  entirely 
healed,  the  wound  in  the  vesico-vaginal  septum  may  be  closed. 
Union  soon  takes  place  in  most  of  these  cases,  if  not  interfered 
with.  The  after  treatment  should  be  the  same  as  when  the  tmnor  is 
removed  through  the  urethra. 

I  need  hardly  say  that  when  the  general  system  is  below  par,  it 
should  be  attended  to. 

Polypus  of  the  Bladder. — Dr.  Godson  showed  a  polypus  which  he 
had  recently  removed  from  a  woman  aged  sixty,  who  was  under  his 
care  in  St.  Bartholomew's  Hospital.  He  first  saw  her  a  year  ago, 
when  she  complained  of  bleeding  from  the  vagina.  The  uterus  and 
vagina  were  found  healthy,  there  had  been  no  recurrence  of  the 
haemorrhage  until  a  week  since  when  the  patient  again  presented 
herself.  On  examination  a  tumor  the  size  of  a  walnut  was  found 
at  the  orifice  of  the  vagina.  It  had  at  first  sight  the  aspect  of  a 
firm  fibrinous  clot ;  it  was  discovered,  however,  to  protrude  from 
the  urethra,  and  to  be  connected  by  a  narrow  pedicle  with  the  fun- 
dus of  the  bladder,  which  organ  it  partially  inverted.  Dr.  Godson 
applied  a  catgut  ligature,  and  separated  it  with  scissors.  A  micro- 
scopical examination  showed  it  to  consist  of  fibro-cellular  tissue, 
with  a  few  muscular  fibers  covered  over  with  mucous  membrane. 
Such  polypi  are  of  extreme  rarity,  and  it  was  fortunate  that  the 
subject  of  it  was  a  woman. — {Obstetrical  Journal,  Aj)7'il  1879, 
p.  28). 

Excision  of  Papilloma  of  Bladder. — ]\I.  C,  aged  thirty -four,  was 
admitted  to  the  St.  Mary's  Hosjiital,  under  the  care  of  Mr.  Norton, 
suffering  from  the  effect  of  long-continued  haemorrhage  of  the 
bladder.  On  examination  j)^^"  urethram,  a  tumor  one  inch  square, 
coated  with  phosphatic  calcuhis,  but  not  nuich  raised  above  the 
mucous  membrane,  was  discovered  oceup^-ing  the  trigone  about  half 
an  inch  from  the  sphincter.  It  was  evident  that  the  tumor  must  be 
removed,  and  the  patient  submitted  to  the  risks  attendant  upon  a 
severe  operation,  or  she  must  be  left  to  endure  the  tortures  brought 
about  by  the  contractions  of  the  bladder  upon  the  growth  after 
micturition,  and  with  the  certainty  of  an  early  death  from  hsemor- 


NOK-INFLAMMATORY  DISEASES  OF  THE   BLADDER.       811 

phage  or  from  blood-poisoning.  It  was  impossible  to  remove  the 
growth  through  the  urethra,  and  it  was  decided  to  cut  the  mass  away 
by  opening  the  vagina.  It  was  considered  that  the  growth  could 
not  be  cleared  without  cutting  through  the  urethra,  and  the  opera- 
tion was  performed  as  follows :  The  spring-scissors  were  inserted, 
one  blade  into  the  bladder  nearly  up  to  the  tumor  and  the  other 
into  the  vagina,  and  closed ;  the  front  wall  of  the  vagina  was  then 
incised  centrally  to  within  half  an  inch  of  the  uterus,  and  the  vaginal 
wall,  which  was  found  not  to  be  incoi-porated  with  the  growth  was 
dissected  from  the  bladder;  the  growth  was  then  seized  with  the 
vulsellum  forceps,  and  drawn  forward,  and  was  then  excised  by  the 
scissors  and  removed.  Bleeding  was  averted  by  the  actual  cautery, 
and  the  lateral  flaps  of  the  vagina  approximated  by  sutures.  To 
prevent  further  hsemorrhage  a  catheter  was  inserted,  and  the  bladder 
compressed  by  plugging  the  vagina ;  no  haemorrhage  of  importance 
took  place.  The  temperature  remained  below  normal,  and  the 
pulse  rose  to  120.  Severe  vomiting  persisted  until  the  tenth  day 
after  the  operation,  when  she  was  considered  out  of  danger.  On 
the  twelfth  day,  when  apparently  in  health,  she  vomited,  and  shortly 
afterward  fell  asleep,  in  which  sleep  she  died  from  syncope.  At 
the  autopsy  the  wound  was  green,  and  sloughing  upon  the  surface, 
but  healthy  immediately  beneath.  ISo  peritonitis  or  cellulitis  was 
present,  or  any  thrombosis  of  vesical,  pelvic,  or  iliac  veins.  A 
microscopical  examination  showed  the  tumor  to  be  a  papilloma. 
Since  writing  this  case  Mr.  Norton  had  operated  upon  a  second  case 
of  tumor  of  the  bladder,  which  had  completely  recovered  from  the 
effects  of  the  operation. — The  Medical  Press  mid  Circidar^  May 
U,  1879;  and  Medical  Record,  Jidy  26,  1879,  pp  82  and  83. 

Tubercle  of  the  Bladder. — Tubercle  of  the  female  bladder  is  a 
comparatively  rare  affection.  Winckel,  of  Germany,  in  2,505 
autopsies,  found  it  but  four  times.  Though  not  often  existing  as  an 
accompaniment  of  pulmonary  tuberculosis,  it  does  not  occur  alone, 
but  is  usually  accompanied  by  similar  deposits  in  the  intestines, 
kidneys,  liver,  and  elsewhere.  It  is  usually  found  in  early  life, 
though  cases  have  been  recorded  where  it  occurred  as  late  as  the 
sixty-fifth  year. 

The  favorite  site  for  its  first  appearance  is  at  the  vesical  neck,  or 
about  the  meatus  urinarius,  these  places  being  rich  in  minute  glands 
and  follicles.  The  deposits  appear  as  minute  white  or  yellowish 
white  points  on  a  red,  indurated  base.  After  a  time,  owing  to  their 
coalescing  and  breaking  down,  large  spots  of  ulceration  result. 

With  these  deposits  in  the  bladder  there  are  very  apt  to  be  simi- 


812  DISEASES  OF  WOMEN. 

lar  deposits  in  the  kidneys  and  ureters,  giving  rise  to  destruction 
of  the  former  and  tubercular  pyelitis  in  the  latter. 

Symptomatology. — The  symptoms  are  at  first  those  of  irrita- 
tion, and  later  of  true  cystitis,  with  ulceration,  induration,  and 
hypertrophy. 

Diagnosis. — The  diagnosis  may  be  made  by  means  of  the  endo- 
scope, if  there  is  opportunity  to  make  early  and  repeated  examina- 
tions. If  by  chance  the  deposits  are  located  at  the  neck  of  the 
bladder,  where  they  can  be  seen  and  watched  going  on  to  ulcera- 
tion, the  diagnosis  is  not  impossible.  The  history  of  the  case 
and  the  presence  of  the  tubercular  diathesis  will  also  aid  in  the 
final  conclusions.  The  urine  examined  by  the  microscope  is  found 
to  contain  a  granular  matter  mixed  with  the  pus  of  cystitis  which  is 
sooner  or  later  produced.  In  case  the  microscopist  is  fortunate  iu 
finding  the  bacillus  tuberculosis  the  diagnosis  is  sure. 

Prognosis. — The  prognosis  is  bad,  as  there  usually  exists  serious 
trouble  of  the  same  nature  elsewhere,  and  as  local  treatment  accom- 
plishes very  little,  the  end  comes  much  sooner  if  the  kidneys  and 
ureters  are  involved  in  the  disease. 

Treatment. — Local  treatment  is  out  of  the  question,  except  such 
as  may  allay  the  irritation  or  inflammation  to  a  certain  extent,  and 
prevent  undue  pain  and  spasm.  This  is  not  leadily  done.  Daily 
cleansing  of  the  viscus  with  warm  water;  opium,  and  belladonna 
suppositories,  or  enemata  of  atropine,  are  the  best  methods  of  treat- 
ment. 

Warmth,  attention  to  diet,  general  tonics,  cod-liver  oil,  and  the 
various  remedies  used  in  phthisis  pulmoualis  should  be  advised. 

Malignant  Growths. — These  are  not  common,  although  occurring 
more  often  than  the  benign  growths.  They  are  usually  secondary, 
and  may  be  of  different  varieties,  as  sarcoma,  scirrhus,  encephaloid, 
epithelial,  villous,  and  even  colloid  cancer.  Sarcoma,  scirrlms, 
colloid,  and  epithelial  are  very  rare ;  encephaloid  and  villous  are 
more  common. 

Symptomatology. — The  symptoms  are  the  same  as  those  of  the 
benign  tumors,  differing  only  in  the  greater  extent  and  severity  of 
the  pain,  and,  as  a  rule,  less  hemorrhage.  The  condition  of  the  gen- 
eral system  is  usually  low,  the  patient  soon  becoming  feeble  and 
cachectic.  Cancerous  deposits  in  the  kidney  and  extension  of  the 
inflammation  up  the  ureters,  may  produce  renal  destruction  and 
consequent  uraemia. 

Diagnosis. — The  only  means  of  making  an  absolute  diagnosis  is 
by  using  the  endoscope,  and  removing  a  bit  of  the  tumor  with 


NON-INFLAMMATORY  DISEASES   OF  THE  BLADDER.       813 

the  curette,  and  submitting  it  to  a  microscopical  examination. 
Sarcoma  and  scirrlms  may  exist  either  as  distinct  tumors  or  as 
diffused  indurations.  The  encephaloid  variety  usually  grows  rap- 
idly, and  is  very  soft,  and  easily  broken  down.  I  have  already  said 
that  cancer  of  neighboring  organs  may  open  into  the  bladder  and 
produce  most  serious  results,  sooner  or  later  involving  the  bladder- 
tissue  in  the  destructive  process.  In  any  case,  adhesion  to  the 
neighboring  organs  takes  place,  and  the  disease  is  liable  to  extend. 
Thrombosis  of  the  veins  of  the  vesical  neck  is  apt  to  occur  and  lead 
to  embolus  elsewhere.     Peritonitis  is  a  frequent  accompaniment. 

The  favorite  seat  of  cancer,  especially  of  the  villous  form,  is  at 
the  trigone.  Some  authors  deny  the  existence  of  villous  cancer, 
saying  that  it  is  simply  a  luxuriant  growth  of  vesical  papilloma, 
and  base  their  opinion  upon  the  nature  of  its  structure  and  certain 
facts  in  its  clinical  history.  "  They  never  lead  to  secondary  can- 
cerous deposits  elsewhere.  They  do  not  spontaneously  ulcerate. 
The  lymphatic  glands  are  not  implicated.  There  is  no  characteristic 
cachexia.  When  they  kill,  death  seems  due  purely  to  loss  of  blood 
and  exhaustion  from  pain." —  Van  Buren  and  Keyes,  j)'  ^57. 

Most  German  authors  claim  that  this  growth  is  malignant,  and 
think  that  in  drawing  deductions,  such  as  I  have  given  above,  the 
observers  saw  only  cases  of  simple  non-malignant  papilloma. 

Causation. — Nothing  is  known  about  the  causes  of  malignant 
disease  of  the  bladder,  excej^t  that  which  is  known  about  malignant 
disease  elsewhere,  consequently,  that  subject  need  not  be  discussed 
here. 

Treatment. — If  the  disease  is  not  too  far  advanced,  extirpation 
or  breaking  down  of  the  tumor  may  be  advisable,  but  except  in  the 
case  of  epithelioma,  and  the  so-called  villous  cancer,  but  Kttle  good 
is  to  be  hoped  for. 

When  removal  is  not  advisable,  we  must  look  to  narcotics  and 
tonics  to  prolong  the  patient's  life  and  relieve  the  intense  pain  and 
tenesmus. 

If  the  tumor  is  generally  distributed  throughout  the  bladder,  or 
has  its  origin  in  a  neighboring  organ,  extirpation  is  out  of  the 
question. 

Sarcomatous  Tumor  of  the  Bladder. — Dr.  L.  A.  Stimson,  at  a  society 
meeting,  exhibited  a  tumor  of  the  bladder  removed  from  a  gentleman 
sixty-three  years  of  age.  When  admitted  to  the  Presbyterian  Hos- 
pital in  the  early  part  of  October,  the  patient  complained  of  frequent 
and  painful  passage  of  bloody  urine.  His  first  attack  occured  in  the 
early  part  of  July,  and  two  or  three  weeks  after  a  fall  from  a  buggy. 


814  DISEASES   OF   WOMEN. 

For  the  previous  four  years  he  gave  a  history  of  attacks  of  so-called 
bilious  colic,  which  in  connection  with  his  bladder  trouble  gave  rise 
to  the  suspicion,  in  the  mind  of  Dr.  Stinison,  of  renal  colic,  and  the 
possible  existence  of  vesical  calculus.  After  unavailing  efforts  to 
reduce  the  irritability  of  the  bladder  the  patient  was  sounded  for 
stone  with  negative  results.  A  subsequent  examination  was  also  of 
a  negative  character.  The  use  of  the  searcher  was  followed  each 
time  by  blood  in  the  urine  for  two  or  three  days  consecutively. 
Examination  j9<?;' r<?(?^i^»2/ revealed  enlargement  of  the  prostate,  and 
fulness  and  doughiness  about  the  bladder,  which  condition  was  sup- 
posed to  be  due  to  cystitis.  The  existence  of  a  tumor  was  suspected, 
but  the  suspicion  could  not  be  confirmed,  inasmuch  as  the  condition 
of  the  patient  forbade  bimanual  exploration.  Ruling  out  the  prob- 
ability of  the  existence  of  a  tumor  of  the  bladder,  pyelitis  was 
thought  of  as  a  cause  ior  his  trouble.  Tlie  patient  died  rather 
suddenly  without  a  positive  diagnosis  having  been  made.  At  the 
autopsy,  and  before  the  body  was  opened,  bimanual  palpation  was 
performed,  and  the  existence  of  a  tumor  was  made  out.  On  open- 
ing the  bladder  the  morbid  growth,  which  proved  to  be  a  sarcoma, 
three  inches  in  diameter,  was  attached  by  a  pedicle  as  thick  as  the 
finger  to  the  posterior  surface  of  the  bladder,  about  four  inches 
above  the  neck  of  the  organ. 


HYPERFLASIA. 

Hyperplasia  of  the  bladder  may  be  partial  or  total ;  may  be  con- 
fined to  the  muscular,  mucous,  or  connective  tissue.  In  using  the 
term  hyperplasia  reference  is  usually  made  to  an  increased  thickness 
of  the  muscular  walls  alone.  There  usually  coexists  with  this  con- 
dition (which  is  partly  hypertrophy,  partly  hyperplasia)  increase  in 
thickness  of  the  various  other  structures  of  the  organ.  This  may  or 
may  not  be  the  case,  and  when  existing  it  is  more  hyperplasia  than 
hypertrophy.  The  terms  partial  and  total  have  been  used  to  convey 
the  idea  of  hypertrophy  of  a  part  or  parts  of  the  muscular  tissue,  and 
do  not  usually  refer  to  the  number  of  coats  involved.  The  truth  is, 
however,  that  one  part  of  the  muscular  tissue  of  the  organ  seldom 
becomes  hypertrophied  to  any  extent  without  involving  the  other 
parts;  the  increase  in  one  part  simply  being  greater  than  in  another. 

This  affection  is  much  less  frequent  in  the  female  than  in  the 
male,  owing  to  her  exeujption  from  the  more  conmion  causes  of  it. 
Any  obstruction  to  the  outflow  of  urine,  as  tumors  of  the  urethra 
or  bladder,   partly  or  wholly  blocking  the  passage ;  cystocele,  by 


NON-INFLAMMATORY   DISEASES   OF  THE   BLADDER.       815 

preventing  complete  evacuation  ;  inflammatory  or  nervous  troubles, 
causing  unusually  active  muscular  contraction,  continuing  for  some 
time  ;  all  these  may  produce  muscular  hyperplasia.  Inflammation 
of  the  mucous  membrane  is  almost  always  present ;  sooner  or  later, 
that  membrane  becomes  to  a  certain  extent  thickened,  and  may  go 
as  far  as  the  production  of  tufty,  polypoid  hyperplasia.  Van  Buren 
and  Keyes  state  that  Civiale  mentions  hypertrophy,  chiefly  of  the 
anterior  vesical  wall,  due  to  chronic  inflammation  or  tubercular  in- 
filtration— evidently  not  simple  hypertrophy. 

As  the  production  of  hypertrophy  is  almost  always  due  to  some 
obstruction  to  the  outflow  of  the  urine,  dikxtation  after  a  time  oc- 
curs, producing  eccentric  hyperplasia.  When  dilatation  does  not 
occur,  but  hyperplasia  alone,  the  condition  is  produced  which  is 
known  as  concentric  hyperplasia.  In  these  cases  of  muscular  hyper- 
trophy in  which  great  force  is  required  to  expel  the  urine,  pouches 
are  sometimes  formed,  usually  at  the  inferior  fundus,  caused  by  the 
pushing  of  the  mucous  membrane  between  the  enlarged  nmscular 
fibers.  These  diverticula  are  comparatively  rare  in  the  female.  A 
sagging  or  dislocation  of  the  entire  posterior  inferior  bladder-wall 
need  not  be  discussed  here,  as  it  has  been  already  disposed  of. 

Symptomatology. — In  concentric  hyperplasia  there  is  usually  vesi- 
cal spasm,  some  pain,  and  forcible  ejection  of  urine.  A  certain 
amount  of  cystitis  almost  always  accompanies  this  affection,  and 
surely  aggravates  the  original  disorder,  by  which  it  is  itself  fm'ther 
aggravated.  In  the  eccentric  form  the  symptoms  are  almost  the 
same,  there  being  sometimes  superadded  those  of  overdistention. 

Diagnosis. — This  is  readily  made  by  introducing  the  finger  into 
the  vagina  and  the  sound  into  the  bladder,  by  which  means  the  ca- 
pacity of  the  organ  can  be  measured  and  the  thickness  of  its  walls 
ascertained.  It  is  not  unusual  in  the  concentric  form  for  the  sound 
to  be  forcibly  expelled  from  the  bladder  by  a  sudden  contraction  of 
that  organ.  The  capacity  of  the  viscus  can  be  further  measured  by 
noting  the  amount  of  urine  passed  at  each  micturition,  or  by  iiiject- 
ing  into  it  some  bland  solution,  such  as  salt  and  lukewarm  water. 

Treatment. — The  treatment  must  be  directed  to  the  removal  of 
the  cause  when  that  is  possible.  If  due  to  stricture  of  the  urethra 
or  the  presence  of  tumors,  their  removal  is  to  be  considered ;  if  to 
cystocele,  replacement,  and  retention  in  place  by  a  proper  pessary, 
and  other  measures  of  which  I  have  spoken  fully  in  a  previous 
chapter,  must  be  adopted. 

When  existing  in  the  eccentric  form  an  abdominal  belt,  cold 
baths,  cold  douches  to  the  hips,  astringent  injections  into  the  blad- 


810  DISEASES  OF  WOMEX. 

der,  and  electricity,  should  be  tried,  having  first,  where  possible, 
removed  the  cause,  and  palliated  or  cured  the  aggravating  complica- 
tions. Daily  catheterization,  in  cases  of  obstruction  to  the  outflow 
of  urine,  or  where,  without  obstruction  there  is  liability  to  over- 
distentioii,  is  of  great  importance,  and  should  be  practiced. 


ATROPHY. 

So  far  as  I  know  this  is  not  a  common  disease.  Its  recognition 
during  life  being  by  no  means  easy,  and  but  little  attention  being 
paid  to  the  bladder  in  autopsies,  very  little  knowledge  of  its  fre- 
quency is  had.  I  am  inclined  to  believe,  however,  that  it  exists 
oftener  than  is  commonly  supposed.  Its  causes  may  be  ranged 
under  two  heads,  viz.,  constitutional  and  local. 

Constitutional. — In  most  women  from  fifty  years  of  age  upward 
a  degenerative  change  takes  place  in  the  bladder,  as  in  the  other 
pelvic  organs,  and  this  is  a  perfectly  natural  process.  In  this  con- 
dition the  several  coats  are  found  proportionally  changed,  the  three 
sometimes  forming  a  wall  not  much  thicker  than  fine  writing-paper. 
This,  however,  is  extreme  and  uncommon.  The  process  causing 
atrophy  is  one  of  fatty  and  granular  degeneration,  and  often  at  this 
age  the  epithelial  cells  of  the  bladder  found  in  the  urine  are  fatty 
and  granular,  as  is  also  the  case  in  both  the  vesical  and  vaginal  epi- 
thelium of  some  women  just  after  parturition. 

Walls  thus  thinned  by  the  degenerative  changes  of  age  are  of 
course  much  more  liable  to  be  still  further  altered  by  various  causes, 
such  as  paralysis  or  overdistention.  Winckel  attributes  the  cysto- 
cele  of  aged  women  to  atrophy  of  the  bladder-walls,  and  the  result- 
ing retention  of  urine. 

In  soft,  flabby  and  debilitated  women,  and  also  in  men,  an  atro- 
phied condition  of  the  bladder-walls  often  exists,  and  may  lead  to 
rupture.  "  Bonnet,  Hauf,  and  Hunter  (quoted  by  Pitha),  give  ex- 
amples of  sudden  ruptme  of  the  bladder  in  young  persons  from 
this  cause  (atrophy).  Civiale  gives  the  caution  of  avoiding  pressure 
on  the  bladder-walls  during  catheterization,  for  fear  of  perforation." 
—  Yan  Buren  and  Keyes. 

Local  Causes.— ^xtvem.Q  distention  of  the  bladder,  leading  to 
temporary  or  permanent  paralysis,  or  paralysis  with  resulting  over- 
distention, may  lead  to  fatty  degeneration  and  atrophy,  as  well  as 
inflammatory  trouble.  Interrupted  nutrition,  due  to  shutting  off 
the  circulation,  is  the  usual  method  of  causation.  Nutritive  changes 
may  also  be  due  to  lack  of,  or  to  perverted,  innervation  caused  by 


NON-INFLAMMATORY  DISEASES   OF  THE  BLADDER.       817 

disease  or  injuries  of  the  spinal  cord.  When  atrophy  occurs  in 
women  under  iifty  years  of  age,  who  are  in  otherwise  good  health, 
and  of  good  constitution,  I  beheve  that  it  is  due  to  habitual  over- 
distention  of  tlie  bladder  from  retention  of  urine. 

Treatment. — Daily  use  of  the  catheter,  strychnia  in  pretty  full 
doses,  electricity,  building  up  of  the  general  system,  and  gentle 
washing  out  of  the  organ  with  warm  medicated  solutions,  may  be 
tried.     But  little  can  be  done  when  the  degeneration  is  due  to  age. 

Atrophy  of  the  Bladder  from  the  Habit  of  retaining  the  TTriae  for 
a  Long  Time. — The  lady  was  thirty-three  years  of  age,  large,  and 
well  developed,  except  that  her  heart  and  arteries  were  rather  small. 
Her  uterus  was  also  undersized.  She  began  to  menstruate  at  fifteen 
years  of  age,  and  her  menses  were  irregular  in  recurrence  and  dura- 
tion, and  always  attended  with  pain.  Early  in  life  she  became  a 
school-teacher,  and  had  followed  that  profession  up  to  the  time  that 
I  saw  her.  She  fell  into  the  habit  of  retaining  her  urine  for  long 
periods,  and  for  several  years  urinated  only  twice  in  each  twenty- 
four  hours.  For  some  time  she  had  noticed  a  growing  difficulty  in 
emptying  her  bladder,  and  five  months  before  consulting  me  she 
found  that  she  had  lost  the  power  of  urinating  altogether.  Her 
physician  used  the  catheter  regularly  for  a  time,  and  then  taught 
her  to  use  it  herself.  Under  this  treatment,  with  tonics  and  seda- 
tives, she  gradually  regained  a  partial  control  of  her  bladder;  but 
with  it  came  an  irritable  condition  of  that  organ  and  the  urethra, 
which  caused  an  almost  constant  desire  to  urinate. 

When  I  examined  her  I  found  slight  prolapsus  of  the  base  of  the 
bladder,  and,  by  passing  a  sound  into  it,  and  a  finger  in  the  vagina, 
I  found  the  posterior  bladder-wall  quite  thin.  There  were  also  in- 
dications of  a  slight  catarrh  of  the  organ,  doubtless  brought  on  by 
the  continued  overdistention  and  prolonged  use  of  the  catheter.  She 
told  me  that  she  had  to  make  strong  efforts  to  pass  m'ine,  and  that 
it  came  away  in  interrupted  jets. 

My  impression  of  this  case  is,  that  her  constant  neglect  of  the 
bladder  function  caused  overdistention,  which  led  to  atrophy  and 
further  distention.  The  use  of  the  catheter  permitted  the  organ  to 
partially  regain  its  muscular  power,  and  also  excited  some  catarrh. 
Passing  the  urine  in  spurts  or  jets  was  due,  I  presume,  to  the  volun- 
tary muscular  efforts. 


53 


CHAPTER  XLYI. 

DISEASES    OF    THE   URETHRA    AJ^D    URETHRAL    GLAKDS. 

Having  finislied  the  consideration  of  the  diseases  which  affect 
the  bladder,  I  now  invite  attention  to  those  which  affect  the  ure- 
thra and  its  glands.     These  may  be  divided  into  two  classes : 

I.  Functional  diseases. 

II.  Organic  diseases. 

I.    FUNCTIONAL  DISEASES  OF  THE  URETHRA. 

I  know  of  but  one  form  of  affection  which  properly  comes  under 
this  head,  and  that  is  commonly  denominated  neuralgia.  A  case  will 
be  occasionally  met  in  which  there  are  pain  and  tenderness  of  the 
urethra,  with  frequent  desire  to  urinate,  and  pain  in  doing  so.  In 
short,  there  is  a  history  of  subacute  urethritis ;  but,  upon  the  most 
careful  examination  that  can  be  made,  with  all  the  means  at  one's 
command,  there  will  be  failure  to  find  any  lesions  to  account  for  the 
symptoms  present.  To  this  condition  the  name  neuralgia  has  been 
applied,  rather  improperly,  no  doubt.  From  my  own  observation  of 
this  affection,  in  which  there  are  well-marked  symptoms,  with  no 
apparent  anatomical  lesions,  I  have  been  led  to  the  conclusion  that 
it  is  a  disease  of  the  nerves  of  the  part — one  of  the  neuroses,  as  they 
are  called.  It  is  quite  possible,  however,  that  progress  in  the  diag- 
nosis of  urethral  diseases  may  yet  enable  diagnosticians  to  find  lesions 
other  than  of  the  nerves  to  account  for  the  symptoms  presented  by 
the  disease  in  question.  But  for  the  present  it  must  be  classed 
among  the  neuroses. 

So  far  as  I  know,  it  is  an  affection  peculiar  to  young  women.  I 
have  only  seen  it  among  young  married  women  of  marked  nervous 
temperament,  and  who  have  not  borne  children.  In  some  of  the 
cases  observed,  it  was  associated  with  an  irritable  condition  of  the 
introitus  vulvae. 


DISEASES   OF   THE   URETERA   AND    URETHRAL   GLANDS.  819 

The  symptoms  are  sucli  as  occur  in  a  great  variety  of  jjathologi- 
cal  conditions,  and  are,  therefore,  of  little  value  in  guiding  to  a  cor- 
rect idea  of  the  real  trouble  ;  and,  as  there  are  no  diagnostic  jjhysical 
signs  present,  the  diagnosis  must  be  made  by  exclusion.  The  most 
thorough  examination  of  the  urine  should  be  made,  and  the  urethra 
and  neighboring  organs  should  be  carefully  investigated.  Perhaps 
the  greatest  liability  to  error  lies  in  mistaking  this  condition  for 
reflex  irritation  of  the  urethra  and  bladder,  arising  from  ovarian, 
uterine,  or  rectal  disease.  Careful  inquiry  into  the  condition  of 
those  organs  should  therefore  be  made  before  concludino^  that  the 
disease  is  of  the  urethra  itself. 

The  aifection  is  fortunately  rare  as  well  as  obscure.  I  will,  there- 
fore, relate  the  history  of  some  cases,  which  will  give  the  facts  as 
they  were  observed  clinically. 

ILLTJSTKATIVE   CASES. 

One  case  was  that  of  a  lady  of  a  highly  nervous  temperament, 
whose  parents  died  of  tuberculosis.  She  was  twenty- six  years  of  age, 
and  had  been  married  three  years.  From  the  time  of  her  marriage 
she  began  to  suffer  from  painful  menstruation  and  uterine  leucor- 
rhoea.  She  attributed  her  trouble  to  getting  cold  while  driving  in 
an  open  carriage  behind  a  fast  horse.  She  had  an  anteflexion  of  the 
uterus  and  cervical  endometritis.  The  right  ovary  was  large,  tender, 
and  prolapsed.  Before,  during,  and  after  her  menses  she  had  smart- 
ing and  burning  pain  in  the  urethra,  with  a  feeling  of  spasmodic 
contraction,  which  sometimes  rendered  urination  di  Si  cult  and  pain- 
ful. In  the  interval  between  the  menstrual  periods  she  had  tender- 
ness of  the  urethra  and  discomfort  in  passing  urine. 

The  urethra  was  repeatedly  examined  throughout  its  whole  extent 
with  the  endoscope,  but  no  disease  could  be  found,  only  tenderness 
and  spasmodic  action. 

She  derived  relief  from  suppositories  of  morphine  and  bella- 
donna, but,  when  last  seen,  she  still  had  attacks  of  the  same  trouble. 
It  was  supposed,  at  first,  that  the  urethral  trouble  was  due  to  the 
disease  of  the  uterus,  but  the  former  persisted  after  the  latter  was 
relieved. 

Another  case  was  that  of  a  lady,  aged  twenty-nine,  who  had  been 
married  for  seven  years,  but  had  never  been  pregnant.  She  was  of  a 
highly  nervous  temperament,  but  her  general  health  had  always  been 
good.  She  began  to  menstruate  at  fourteen  years  of  age,  and  con- 
tinued to  do  so  regularly,  but  scantily.  For  several  years  she  had 
suffered  from  backache  and  slight  uterine  leucorrhcea,  and  coitus  had 


820  DISEASES   OF  WOMEN. 

always  been  painful.  She  had  frequent  and  painful  urination.  The 
nteras  was  small — in  fact,  all  the  reproductive  organs  were  under- 
sized. There  was  marked  tenderness  of  the  introitus  vulvae.  The 
remains  of  the  hymen  were  very  tender,  and  at  the  meatus  urinarius 
and  on  the  vestibule  there  were  a  number  of  quite  small  papillomata 
(of  the  same  color  as  the  mucous  membrane)  that  were  also  exceed- 
ingly tender.  These  were  destroyed  by  an  application  of  equal  parts 
of  carbolic  acid  and  tincture  of  iodine,  and  the  leucorrhoea  was  ar- 
rested by  the  usual  treatment.  This  relieved  her  of  ail  the  symptoms 
except  those  of  the  urinary  organs.  Her  urine  was  examined  repeat- 
edly, and  was  found  to  be  normal.  The  urethra  was  also  investi- 
gated, but  nothing  wrong  was  found  there  except  that  the  papillae 
appeared  to  be  miusnally  prominent.  I  learned  that  if  she  retained 
the  urine  for  an  hour  or  two  the  desire  to  urinate  passed  off,  and 
did  not  return  until  the  bladder  was  fully  distended.  When  she  did 
urinate,  the  desire  to  empty  the  bladder  continued — i.  e.,  she  had 
vesical  tenesmus — but,  if  she  indulged  this  feeling  by  passing  the 
urine  repeatedly,  this  tenesmus  continued ;  while,  if  she  resisted  the 
desire,  it  gradually  subsided.  This  proved  conclusively  that  the 
cause  of  the  frequent  m-ination  was  the  condition  of  the  urethra. 

Quite  a  variety  of  agents,  which  I  need  not  give  in  detail  here, 
were  tried  in  this  case.  Suffice  it  to  say  that  she  only  derived  bene- 
fit from  coating  the  entire  nmcous  membrane  of  the  urethra  with 
dry  subnitrate  of  bismuth  once  a  day  for  a  week,  and  then  applying 
equal  parts  of  tincture  of  aconite  and  aqueous  extract  of  opium 
twice  a  week  for  a  time.  The  bismuth  was  made  into  an  enuilsion 
with  water  and  a  little  acacia,  and  applied  with  the  pipette.  A  steel 
sound  was  also  passed  once  a  week,  and  allowed  to  remain  in  place 
for  about  five  minutes.  This  gave  pain  at  the  time,  but  relief  fol- 
lowed. During  the  local  treatment  she  took  nourishing  food,  iron, 
and  arsenic.  She  may  be  said  to  have  recovered  ;  but  overtaxation, 
mental  or  physical,  w^ould  bring  back  the  trouble  in  a  slight  degree 
for  a  short  time. 


II.  ORGANIC   DISEASES   OF   THE   URETHRA. 

This  class  may  be  subdivided  into  ten  groups. 

1.  Inflammation  or  urethritis. 

2.  Granular  erosion. 

3.  Yesico-urethral  fissure. 

4.  Neoplasms. 

5.  Dilatation. 


ORGANIC  DISEASES   OF  THE   URETHRA.  821 

6.  Dislocation. 

7.  Prolapsus. 

8.  Stricture. 

9.  Foreign  bodies. 
10.  Fistula. 

1.  Inflammation  of  the  Urethra,  or  Urethritis. — This  is  of  three 
varieties  [a)  acute,  {h)  clironic,  and  (c)  gonorrlioeal. 

Acute  urethritis,  though  not  a  very  frequent  disease  among 
women,  is  a  very  distressing  one,  and  often  difficult  to  relieve.  In 
many  cases  it  will  be  found  to  depend  upon  a  specific  cause,  that  is, 
gonorrhoea ;  and  I  would  treat  this  subject  as  gonorrhoea  in  women, 
were  it  not  that  it  is  often  difficult  to  tell  a  specific  or  venereal  ure- 
thritis from  simple  inflammation  of  that  portion  of  mucous  mem- 
brane. There  is  a  difference  in  the  history  when  correct  testimony 
is  obtained  from  the  patient.  Simple  urethritis  usually  comes  on 
gradually,  and  is  often  preceded  by  symptoms  of  uterine  or  vesical 
disease ;  while  the  gonorrhoeal  variety  comes  on  rather  abruptly,  and 
is  preceded  or  attended  by  acute  vaginitis  and  vulvitis.  The  chief 
symptom  in  both  varieties  is  painful  urination.  Sharp  scalding  is 
produced  by  the  urine  passing  over  the  tender  surface.  There  is 
often  a  frequent  desire  to  urinate,  but  not  so  urgent  as  in  cystitis.  In 
some  cases  the  urine  is  retained  for  a  long  time,  evidently  from  a 
dread  of  the  pain  caused  in  passing  it. 

In  quite  a  number  of  cases  I  have  noticed  hsemorrhage.  That 
the  blood  comes  from  the  urethra  is  known  by  the  fact  that  it  is  not 
intimately  mixed  with  the  urine ;  and  after  micturition  it  will  ooze 
from  the  meatus  urinarius. 

An  examination  of  the  parts  will  show  signs  of  inflammation 
about  the  meatus,  with  or  without  the  same  condition  of  the  vulva. 
Occasionally,  there  is  a  discharge  seen  coming  from  the  urethra,  but 
if  the  parts  have  been  recently  bathed  this  may  not  be  apparent. 
Introducing  the  finger  into  the  vagina,  and  pressing  upon  the  urethra 
from  above  downward,  the  discharge  can  be  started,  unless  the  pa- 
tient has  passed  water  immediately  before.  The  appearance  of  the 
discharge  corresponds  to  that  of  gonorrhoea  in  its  various  stages. 
An  examination  of  the  discharge  with  the  microscope  may  reveal 
the  presence  of  the  gonococcus,  and,  if  so,  that  will  determine  the 
nature  of  the  urethritis.  The  absence  of  that  germ  is  not  positive 
proof  that  the  inflammation  is  not  gonorrhoeal,  unless  frequent  and 
skilled  examinations  fail  to  find  it. 

Cystitis,  which  is  liable  to  be  confounded  with  urethritis,  may  be 
excluded  by  using  the  catheter,  and  after  letting  urine  flow  for  a 


822  DISEASES   OF  WOMEN. 

time,  collecting  the  remainder  for  examination.  The  mucous  mem- 
brane, as  seen  through  the  endoscope,  is  of  a  deep  red,  with  pus  or 
mucus  lodged  in  its  folds.  The  instrument  can  not  be  used  in  all 
cases,  owing  to  the  acute  tenderness  of  the  jjarts.  Bleeding  is  very 
likely  to  occur  at  the  examination,  simply  from  the  contact  of  the 
endoscope. 

The  treatment  of  acute  urethritis,  whether  specific  or  not,  may  be 
conducted  on  the  same  principles  as  that  of  gonorrhoea  in  the  male, 
using  the  same  constitutional  remedies,  local  baths,  etc.  This  will 
suffice  in  most  cases  of  acute  disease ;  but  when  it  assumes  the  sub- 
acute form  from  the  beginning,  then  the  use  of  injections  becomes 
necessary. 

Dr.  Avery  Segur,  of  Brooklyn,  finds  that  the  discharge  of  gonor- 
rhoea is  markedly  lessened,  and  sometimes  cured,  by  ten-grain  doses 
of  salicylic  acid,  given  in  solution  several  times  a  day. 

I  have  seen  mucli  benefit  derived  from  douching  the  urethra 
with  water  as  hot  as  the  patient  could  bear  it.  For  this  purpose  I 
use  a  catheter  made  like  the  fluted  roller  of  a  erimping-machine,  the 
appearance  of  which  is  doubtless  familiar.  Fig.  240.    Inside  the  cath- 


FiG.  240. — Skene's  reflux  catheter. 

eter  there  is  a  small  supply-tube,  which  conveys  the  water  to  the 
rounded  point  of  the  instrument.  Behind  the  point  of  the  catheter, 
where  the  grooves  terminate,  there  is  a  perforation  in  each  groove 
through  which  the  water  returns.  By  this  arrangement  the  water  as 
it  flows  back  through  the  grooves  is  brought  in  contact  with  every 
portion  of  the  mucous  membrane.  The  instrament  is  passed  up  to 
the  neck  of  the  bladder,  and  a  fountain -syringe  attached  to  it,  and 
the  water  as  it  flows  away  is  caught  in  a  cup. 

The  injection  of  solutions  of  nitrate  of  silver,  sulphate  of  zinc, 
and  the  like,  will  often  prove  useful.  It  must  be  borne  in  mind  that 
the  female  urethra  will  not  hold  more  than  ten  or  fifteen  drops,  and 
if  more  is  used  it  will  enter  the  bladder,  even  where  but  very  slight 
force  is  employed  while  injecting.  I  use  a  large  pipette,  placing 
the  nozzle  over  (not  in)  the  meatus,  and  inject  slowly  and  without 
force  a  small  quantity.  When  the  case  is  of  long  standing,  and  the 
neck  of  the  bladder  appears  to  be  involved  also,  I  use  a  mild  injec- 
tion of  one  or  two  grains  of  nitrate  of  silver  to  the  ounce,  and  inject 


ORGANIC  DISEASES  OF  THE   URETHRA.  ♦    823 

it  through  the  nretlira  with  force  enough  to  enter  the  bladder,  and 
let  it  remain  there,  to  be  passed  off  when  the  patient  urinates.  In 
acute  urethritis  the  most  efficient  treatment  that  I  have  found  is  to 
wash  out  the  urethra  with  the  reflux  catheter  two  or  three  times  a 
day,  and  then  introduce  a  suppository  of  iodoform  in  cocoa-butter,  or 
bismuth  and  cocoa-butter.  In  old  cases,  which  began  by  a  severe 
acute  attack,  and  where  the  walls  of  the  urethra  are  very  much 
thickened  and  the  canal  contracted,  dilatation  with  bougies  does 
much  good.  While  the  bougie  is  passed  once  or  twice  a  week,  I 
apply  to  the  vaginal  portion  of  the  urethra  oleate  of  mercury  or  the 
ungu^ntum  hydrargyri.  This  will  often  suffice  to  stop  the  gleety  dis- 
charge, as  well  as  remove  the  thickening  of  the  urethral  walls.  The 
case  reported  by  Dr.  Howard,  which  will  be  found  at  the  close  of 
the  consideration  of  the  diseases  affecting  the  urethral  glands,  would 
seem  to  indicate  that  a  gonorrhoeal  urethritis  in  which  these  glands 
are  involved  may  continue  indefinitely  unless  appropriate  treatment 
is  directed  to  them. 

Treatment  of  Chronic  Urethritis  and  Spasm  of  the  Bladder. — Dur- 
ing the  past  ten  years  Weiser  has  adopted  a  new  method  of  treat- 
ment in  chronic  gonorrhoea,  and  out  of  twenty-five  cases  he  has  suc- 
ceeded in  curing  all  but  one.  The  latter  was  afterward  advised  to 
consult  Dr.  Greenfeld,  who,  by  means  of  the  endoscope,  discovered 
granulations  in  the  urethra,  which  being  cauterized,  the  man  got 
well  after  several  weeks'  treatment.  Weiser  first  passes  an  elastic  or 
metallic  catheter  into  the  bladder,  and,  after  thoroughly  evacuating 
the  viscus,  injects  into  it  by  means  of  a  clysopompe,  or,  preferably, 
an  irrigator,  a  solution  of  sulphate  of  zinc,  2  to  3,  and  tannin,  0'5 
in  500  of  water,  at  a  temperature  of  26°  R.  The  catheter  is  then 
withdrawn,  and  the  patient  directed  to  empty  his  bladder,  thus  bring- 
ing the  medicated  solution  in  thorough  contact  with  the  whole  of  the 
urethra.  This  method  is  effectual  in  all  cases  when  no  granulations 
exist.     The  latter  require  the  application  of  caustics. 

The  author  has,  however,  omitted  to  state  how  long  the  treat- 
ment must  be  continued.  In  cases  with  associated  cystitis  three  to 
four  drops  of  nitrite  of  amyl  should  be  added  to  the  above  solution, 
the  former  being  a  very  active  disinfectant — one  or  two  drops  added 
to  a  bottle  of  urine  serving  to  prevent  the  development  of  ammonia 
in  the  latter  for  a  couple  of  years.  When  strictures  are  present  they 
should  be  treated  with  metallic  sounds.  For  the  relief  of  cysto- 
spasms,  the  above-mentioned  solution  may  also  be  employed  ;  one  or 
two  injections  a  day,  continued  for  an  average  period  of  three 
months,  usually  suffice  to  entirely  cure  this  condition.     Frictions 


824  •  DISEASES  OF  WOMEN. 

with  cold  water  and  lukewarm  (2G°  R.)  sitz-baths  may  be  employed 
as  adjuvants. — "  Mittheilungen  (hs  Wiener  Med.,  Doctoren-Collegi- 
ums,  June  ^3,  1881 ;  New  York  Medical  Record,  October  1,  1881, 
p.  375. 

A  Case  of  Chronic  Urethritis  treated  by  Emmet's  Button-Hole 
Operation.  (By  Virgil  O.  Harden,  M.  D.,  Atlanta,  Ga.) — E.  J.,  white, 
widow,  aged  sixty-one,  was  married  at  thirteen,  and  has  borne  nine- 
teen children.  All  her  labors  were  normal,  as  far  as  she  knows,  and 
her  health  had  always  been  good  until  twelve  years  ago.  She  then 
began  to  suffer  from  frequent  desire  for  micturition,  and  the  act  was 
always  accompanied  by  burning  pains.  These  symptoms  gradually 
increased  in  severity,  until  at  the  present  time  she  is  obliged  to  uri- 
nate at  intervals  of  from  fifteen  to  thirty  minutes  throughout  the  day 
and  night.  The  passage  of  urine  produces  an  intense  pain  in  the 
urethra,  especially  at  the  meatus,  radiating  upward  into  the  abdomen 
and  downward  into  the  thighs.  This  pain  persists  for  some  time 
after  micturition,  so  that  she  is  hardly  ever  fres  from  it.  In  other 
respects  her  health  is  good,  but  her  naturally  robust  constitution  is 
breaking  down  under  the  constant  pain  and  annoyance  to  which  she 
is  subjected.  She  is  entirely  unfitted  for  social  or  domestic  duties, 
and  nearly  her  whole  time  and  attention  are  given  to  keeping  her 
bladder  empty. 

Examination  shows  the  meatus  contracted  so  as  to  scarcely  admit 
a  No.  6  sound,  and  surrounded  by  cicatricial  tissue,  forming  bands 
by  which  it  is  much  distorted.  Extreme  tenderness  exists  along  the 
urethra  and  in  the  neck  of  the  bladder.  The  passage  of  a  sound 
gives  exquisite  pain.  The  urethro- vaginal  septum  is  of  abnormal 
thickness  and  density.  Otherwise  the  pelvic  organs  are  found  to  be 
normal. 

The  urine,  of  which  about  an  ounce  is  passed  at  a  time,  is  straw- 
colored  and  slightly  turbid.  Upon  standing  there  is  formed  a  de- 
posit of  about  one  fourth  its  bulk  ;  specific  gravity,  1028.  Chem- 
ical and  microscopical  examination  shows  it  to  be  free  from  albu- 
men, sugar,  pus,  and  mucus.  The  deposit  is  made  up  of  amorphous 
urates. 

The  patient  has  been  treated  by  internal  medication  by  compe- 
tent practitioners,  but  without  receiving  any  apparent  benefit. 

January  23,  1886,  wdth  the  assistance  of  Drs.  Bizzell  and  Wile, 
she  was  etherized,  and  Emmet's  button-hole  operation  was  per- 
formed. An  incision  was  made  through  the  urethro-vaginal  sep- 
tum, commencing  a  quarter  of  an  inch  behind  the  meatus  and  ex- 
tending to  a  quarter  of   an  inch  from  the  neck  of  the  bladder. 


ORGANIC  DISEASES  OF  THE    URETORA.  825 

Through  tliis  opening  the  cut  edge  of  tlie  urethral  mucous  mem- 
brane wa^  drawn,  and  stitched  on  all  sides  to  the  cut  edge  of  the 
vaginal  mucous  membrane  with  carbolized  silk  sutures.  Thus  no 
surface  was  left  uncovered  to  heal  by  granulation.  The  urethral 
mucous  membrane  was  found  to  be  so  intensely  congested  as  to  jire- 
sent  a  deep  purple  color,  and  capillary  oozing  of  blood  from  it  was 
very  free.  The  parts  were  smeared  with  vaseline,  and  the  patient 
was  afterward  instructed  to  make  the  same  application  before  each 
micturition.  The  wound  healed  satisfactorily,  and  the  sutures  were 
removed  on  the  eighth  day,  leaving  a  permanent  urethro-vaginal 
fistula. 

In  the  twenty-four  hours  following  the  operation  the  patient 
urinated  five  times,  with  only  slight  pain.  After  the  second  day 
she  was  entirely  free  from  pain,  and  has  continued  so  ever  since. 
She  urinates  sometimes  twice,  usually  only  once,  and  occasionally 
not  at  all  during  the  night,  and  from  four  to  six  times  during  the 
day.  She  frequently  holds  her  urine  for  six  hours  without  any  dis- 
comfort. The  urine  passes  entirely  through  the  artificial  opening. 
The  pain  at  the  meatus  and  the  tenderness  along  the  urethra  have 
ceased,  and  the  congestion  of  the  urethral  mucous  membrane  is  now 
very  slight. — Atlanta  Medical  and  Surgical  Journal. 

2.  Granular  Erosion. — This  very  troublesome  affection  of  the 
urethra  may  result  from  urethritis,  or  may  appear  without  any  pre- 
vious disease.  The  mucous  membrane  is  covered  with  young,  im- 
perfectly developed  epithelium  ;  the  papillae  are  hypertrophied  and 
extremely  sensitive.  This  gives  rise  to  the  most  excruciating  pain 
during  micturition,  and  generally  keeps  up  a  distressing  tenesmus. 
This  disease  is,  fortunately,  not  very  common.  Old  people  are  most 
liable  to  suffer  from  it.  The  diagnosis  is  made  from  the  history  and 
appearance  of  the  urethra.  The  treatment  which  is  most  reliable  is 
cauterization  of  the  whole  surface.  The  milder  washes  and  injec- 
tions do  not  accomplish  much.  Pure  carbolic  acid  may  be  tried 
first,  brushing  it  over  the  surface,  and  repeating  it  in  eight  or  ten 
days.  This  is  the  least  painful  application,  and  answers  in  some 
cases.  When  it  fails,  a  solution  of  nitrate  of  silver  (one  drachm  to 
the  ounce)  should  be  used.  In  some  cases  it  is  desirable  before 
using  strong  caustics  to  dilate  the  urethra,  and  then  touch  it  with 
carbolic  acid  in  a  mild  solution,  say  two  per  cent. 

Among  the  infiammatory  affections  of  the  female  urethra  ai'e 
mild  forms  of  congestion  and  irritation,  that  fall  short  of  Avell- 
marked  urethritis.  Indeed,  some  of  these  attacks  amount  to  little 
more  than  congestion  or  slight  catarrh.     In  others,  I  have  found 


826  DISEASES  OF  WOMEN". 

circumscribed  patches  of  the  urethra  inflamed,  and  the  rest  of  the 
canal  normal. 

There  is  little,  if  anything,  in  medical  works  on  the  subject  of 
these  mild  yet  troublesome  affections,  and  I  hope  that  a  clear  idea  of 
the  subject  will  be  gained  from  the  narration  of  some  cases  which 
have  come  under  my  observation. 

ILLUSTRATIVE   CASES. 

A  young,  married  lady  had  been  under  my  care  for  dysmenor- 
rhcea  caused  by  anteflexion.  She  had  recovered  sufficiently  to  be- 
lieve that  she  was  well  enough  to  go  to  a  party  and  dance  to  excess, 
which  she  did,  and  caught  cold  on  the  way  home.  On  the  second 
day  after  1  was  called  to  see  her,  and  found  her  with  the  usual 
symptoms  of  an  ordinary  cold,  that  caused  her  little  anxiety.  But 
she  was  suffering  severely  from  frequent  and  painful  micturition. 
I  found  slight  general  congestion  of  the  utenis  and  vagina,  and  sus- 
pected cystitis,  but  the  urine  was  normal.  I  then  examined  the 
urethra,  and  found  it  congested  throughout,  and  with  streaks  of 
mucus  lodged  in  the  folds  of  the  membrane.  There  was  neither 
erosion  nor  ulceration. 

I  directed  her  to  rest  quietly  in  bed,  and  di-ink  freely  of  flaxseed- 
tea  and  spiritus  setheris  nitrosi.  A  suppository  containing  one 
quarter  of  a  grain  of  extract  of  belladonna  and  a  sixth  of  a  grain  of 
sulphate  of  morphia  was  directed  to  be  introduced  into  the  vagina 
at  bed-time.  Under  this  simple  treatment  she  rapidly  improved. 
Twelve  days  after  the  date  of  my  visit  she  called  to  see  me,  and  I 
then  found  that  she  could  retain  her  urine  for  hours,  but  still  had 
slight  pain  and  burning  during  micturition.  The  urethra  was  again 
examined  viith  the  endoscope,  and  a  few  red  patches  found  scat- 
tered here  and  there  along  the  canal.  This  was  all  that  remained  of 
the  trouble.  Liquor  bismuthi,  sufficient  in  amount  to  fill  the 
urethra,  was  injected  every  second  day  for  a  week,  when  she  de- 
clared herself  quite  well. 

A  second  case  was  that  of  a  young  lady,  healthy  and  active,  who 
was  head  saleswoman  in  a  department  of  a  large  dry-goods  estab- 
lishment. During  the  holidays,  from  Christmas  to  New  Year's,  she 
was  on  her  feet  from  eight  in  the  morning  until  ten  or  eleven  at 
night.  On  the  last  day  of  the  year  she  was  seized  with  pain  and 
burning  in  the  urethra,  and  soon  after  she  began  to  suffer  from  fre- 
quent and  painful  micturition. 

Three  or  four  days  after  the  attack  I  examined  the  urethra,  and 
found  several  small  ecchymoses  at  various  parts  of  the  mucous  mem- 


ORGANIC  DISEASES   OF  THE   URETHRA.  827 

brane,  the  highest  one  being  near  the  neck  of  the  bladder.  These 
spots  were  due  to  hsemorrhages  that  had  taken  place  into  the  mucous 
membrane,  beneath  the  epithelial  layer.  The  spots  were  dark,  al- 
most black  in  the  center,  and  surrounded  by  an  inflamed  border, 
which  was  bright  red  at  the  inner  margin,  but  gradually  shaded  oft" 
into  the  natural  color  of  the  surrounding  mucous  membrane. 

My  idea  of  the  pathology  of  this  case  is  that  the  congestion  aris- 
ing from  the  maintenance  of  the  erect  position  for  so  long  a  time 
caused  some  of  the  small  vessels  to  rupture,  and  the  hsemorrhage 
into  the  membrane  produced  little  circumscribed  spots  of  inflam- 
mation. 

She  was  directed  to  rest  in  the  recumbent  position,  and  drink 
freely  of  Yichy  water.  This  she  did,  and  made  a  good  recovery ; 
but  it  w^as  six  or  eight  days  before  the  pain  in  urinating  left  her 
entirely. 

It  will  be  observed  that  these  cases  were  both  acute,  and  recov- 
ered very  promptly ;  and  I  could  give  several  more  histories  which 
might  lead  to  the  supposition  that  such  trivial  ailments  of  the  ure- 
thra are  not  of  much  importance  after  all.  It  might  also  be  pre- 
sumed that  this  form  of  urethral  disease  would  disappear  in  most 
cases  without  being  treated.  This  is  no  doubt  true,  but  they  do 
not  all  recover  spontaneously.  Some  of  these  mild  cases  tend  to 
continue.  They  become  chronic,  and  if  neglected  will  continue  for 
years,  to  the  great  annoyance  of  the  subject.  Of  the  chronic  or 
continuous  form  of  urethritis  the  following  are  good  examples :  A 
single  woman,  thirty  years  of  age,  had  for  ten  years  been  occupied 
as  dressmaker,  and  was  in  the  habit  of  operating  a  sewing-machine 
occasionally.  Her  general  health  had  always  been  excellent,  but  she 
consulted  me  for  what  she  supposed  to  be  an  affection  of  the  kid- 
neys. She  said  that  for  five  years  she  had  been  annoyed  with  pain- 
ful and  frequent  micturition.  She  was  obliged  to  urinate  every  two 
or  three  hours  during  the  day,  and  several  times  in  the  night. 
Standing,  walking,  or  exposure  to  cold  invariably  made  her  worse. 

An  examination  of  her  pelvic  organs  revealed  slight  catarrh  of 
the  cervix  uteri,  and  a  mild  vaginitis,  limited  to  the  upper  and  pos- 
terior portion  of  the  vagina,  most  marked  behind  the  cervix.  Her 
urine  was  examined  carefully  and  found  to  be  normal.  The  urethra 
was  then  examined  by  the  endoscope,  which  brought  to  view  a 
highly  inflamed  spot  on  the  anterior  wall  of  the  urethra,  and  an  in- 
flamed ulcer  on  tlie  posterior  wall.  The  disease  was  limited  to  the 
middle  third  of  the  urethra,  and,  while  extending  all  around,  was 
most  marked  anteriorly  and  posteriorly.     The  ulcer,  which  lay  in 


828  DISEASES  OF    WOMEN. 

the  posterior  wall  or  floor  of  the  urethra,  was  superficial  and  appeared 
through  the  endoscope  as  a  gray  spot  surrounded  by  a  bright  red 
areola.  It  bled  on  contact  with  or  stretchinp;  by  the  instrument. 
The  color  of  the  upper  and  lower  third  of  the  urethra  was  somewhat 
darker  than  usual,  but  otherwise  normal. 

The  recovery  in  this  case  was  somewhat  tedious,  because  it  was 
one  of  my  first  cases,  and  my  treatment  was  experimental  and  not 
always  beneficial.  First,  I  touched  the  inflamed  parts  with  a  solu- 
tion of  nitrate  of  silver  (one  drachm  to  the  ounce),  using  just  enough 
to  whiten  the  surface.  This  gave  her  rather  sharp  pain,  which 
passed  off,  however,  in  a  few  hours.  After  this  she  had  much  pain 
in  passing  water,  but  the  frequency  was  about  the  same  as  before 
the  application.  About  ten  days  after  using  the  solution  the  parts, 
though  still  inflamed,  were  much  improved. 

This  advantage  gained  suggested  a  repetition  of  the  application, 
which  I  made.  It  was  followed  by  very  severe  pain,  that  lasted  two 
days  and  nights  before  it  subsided.  There  was  no  improvement. 
After  this  I  injected  into  the  urethra,  twice  a  week,  a  solution  con- 
sisting of 

5.   Zinci  sulphatis gr.  iv. 

Fl.  ext.  hydrastis  Canadensis 3  j. 

Aquag §  iij.     M. 

About  half  a  drachm  of  this  was  used  at  a  time.  This  was  con- 
tinued for  about  a  month  with  marked  benelit.  At  the  end  of  that 
time  she  could  rest  all  night  without  urinating,  and  had  to  micturate 
only  about  every  four  hours  during  the  day,  and  had  very  little  pain. 
Injection  of  liquor  bismuthi  (half  a  drachm)  was  then  begun,  and 
continued  twice  a  week  for  three  weeks,  when  she  was  free  from  all 
trouble,  but  was  obliged  to  urinate  every  four  or  six  hours,  from 
habit,  I  suppose. 

One  other  case  maybe  given  to  show  the  disposition  of  this  form 
of  urethral  trouble  to  continue.  This  patient  was  thirty-nine  years 
of  ao-e,  and  had  been  a  widow  for  sixteen  years.  Her  onlv  child  was 
a  grown-up  woman.  Four  years  before  I  saw  her  she  had  a  catarrh 
of  the  bladder,  for  which  she  was  treated  by  a  skilled  physician. 
She  recovered  from  that  after  a  time,  the  urine  iiecoming  normal, 
and  the  ability  to  retain  it  excellent.  She  continued,  however,  to 
have  pain  in  passing  urine,  but  as  there  was  no  discomfort  at  any 
other  time  she  was  satisfied  to  tolerate  that. 

Being  troubled  with  constipation  while  traveling,  she  was  taken 
with  agonizing  pain  after  defecation,  continuing  to  suffer  with  it  for 
several  months.     She  then  apphed  to  me  for  relief.     She  stated  that 


ORGANIC  DISEASES   OF  THE   UEETHRA.  829 

the  pain  during  micturition  had  been  much  worse  since  the  develop- 
ment of  the  rectal  pain.  The  rectum  was  examined  witli  the  endo- 
scope (the  same  instrument  used  in  exploring  tlie  bladder  and 
urethra,  but  of  larger  size),  and  a  well-detined  fissure  detected.  This 
explained  the  rectal  symptoms,  and  it  is  fair  to  suppose  that  the 
urethral  ti'ouble  was  aggravated  by  it  sj'mpathetically.  The  lower 
third  of  the  urethra  was  found  to  be  inflamed,  and  in  places  eroded. 
The  anal  fissure  was  relieved  by  the  usual  operation,  and  the  urethra 
was  treated  with  applications  of  nitrate  of  silver  (one  grain  to  the 
ounce).     Recovery  was  speedy  and  satisfactory. 

3.  Vesico-Urethral  Fissure. — This  affection  holds  an  intermediate 
position  between  cystitis  and  urethritis,  and  in  its  symptomatology 
bears  a  marked  resemblance  to  both,  and  I  have  therefore  deferred 
its  consideration  until  both  these  diseases  have  been  treated.  1  am 
fully  satisfied  that  it  is  often  mistaken  for  inflammation  of  the  blad- 
der or  urethra. 

It  is  only  within  the  last  few  years  that  this  trouble  has  been 
brought  to  the  notice  of  the  profession,  and  hence  there  is  very  little 
in  medical  literature  on  the  subject.  This  affection  has  heretofore 
been  called  fissure  of  the  neck  of  the  bladder.  Were  I  to  name  it 
according  to  its  location,  I  should  say  vesico-urethral  fissure,  for  its 
usual  site  is  at  the  point  of  junction  of  the  two. 

The  lesion,  as  the  name  indicates,  is  a  crack  or  fissure  of  the 
mucous  membrane,  produced  by  ulceration.  It  runs  lengthwise  of 
the  urethra,  and  is  situated  in  one  of  the  sulci  or  folds  of  the  mem- 
brane formed  by  the  corrugations  which  always  exist  when  the 
urethra  is  not  distended.  It  is  usually  spoken  of  as  situated  in  the 
vesical  neck,  but  as  a  rule  two  thirds  of  it  is  situated  in  the  urethra, 
the  upper  end  of  it  only  extending  into  the  bladder. 

It  may  occur  at  any  part  of  the  circumference  of  the  urethra. 
In  the  majority  of  the  cases  that  I  have  examined  it  has  been  situ- 
ated on  the  right  side  anteriorly.  Those  who  are  familiar  with  fis- 
sure of  the  rectum  will  understand  that  fissure  of  the  vesical  neck 
is  exactly  the  same  in  appearance,  save  that  it  is  much  smaller.  It 
is  from  a  quarter  to  three  eighths  of  an  inch  in  length,  and  from  one 
twelfth  to  one  sixth  of  an  inch  in  width  at  the  center,  but  tapering 
off  at  each  end. 

The  deepest  part  has  a  yellowish  gray  color,  like  that  of  an  in- 
dolent ulcer,  while  the  edges  are  red  and  actually  inflamed,  like 
those  of  an  irritable  ulcer.  When  seen  through  a  large  endoscope 
that  jKits  the  parts  upon  the  stretch,  it  may  appear  freshly  torn  and 
bleeding.     The  edges  are  usually  abrupt,  elevated,  and  indurated, 


830  DISEASES  OF   WOMEN. 

and  of  a  dark  or  bright  red  color.  This  shades  off  gradually  into 
the  normal  membrane  of  the  urethra. 

The  importance  of  thLs  lesion  depends  upon  its  site.  An  ulcer 
or  lissure  of  the  same  size,  if  situated  in  any  other  portion  of  the 
urethra,  would  cause  little  suffering  beyond  a  smarting  sensation 
during  micturition.  But  occurring  at  the  union  of  the  bladder  and 
urethra  it  is  submitted  to  constant  though  slight  pressure,  which 
causes  severe  and  continuous  pain.  1  believe  that  the  very  great 
suffering  caused  by  this  disease  is  due  lai'gely  to  the  fact  that  these 
parts  of  the  bladder  and  urethra  are  by  far  the  most  sensitive,  and 
that  the  upper  portion  of  the  fissure,  which  extends  into  the  bladder, 
is  exjiosed  to  the  iiritation  of  the  urine,  which  excites  the  constant 
desire  to  urinate.  The  pain  which  is  thus  produced  causes  exces- 
sive contraction  of  the  urethra  and  bladder,  and  this  contraction 
again  causes  pain,  "  the  vicious  circle,"  as  it  is  termed,  being  thus 
established.  In  other  words,  the  cause  produces  an  effect,  which 
in  tui'u,  acts  as  a  cause  and  aggravates  the  original  disorder. 

Symptomatology. — The  symptoms  of  fissure  are  a  constant  desire 
to  urinate,  and  a  feehng  of  burning  pain  at  the  neck  of  the  bladder. 
There  is  acute  pain  both  during  and  immediately  after  the  act  of 
micturition,  and  severe  tenesmus,  which  causes  the  patient  to  make 
voluntary  straining  efforts  at  evacuation  after  the  bladder  is  empty. 
Immediately  after  urination  the  jjaiu  and  burning  are  often  intense. 
After  a  time  it  partially  subsides,  but  again  commences  when  a  lit- 
tle urine  collects  in  the  bladder. 

When  the  patients  resist  the  desire  to  urinate  (as  they  often  do 
at  night  when  unwilling  to  get  up)  the  distress  is  much  aggravated. 
It  will  be  seen  that  all  the  symptoms  mentioned  are  much  the  same 
as  those  presented  in  cystitis,  and  on  that  account  ai"e  not  reliable 
guides  in  diagnosis.  Urethritis  also  gives  rise  to  many  of  the  symp- 
toms named  above,  and  might  be  mistaken  for  urethro-vesical  fissure. 
There  are,  however,  some  points  of  difference  ])et\veen  the  symptoms 
of  these  three  affections  that  are  deserving  of  notice.  In  fissure  the 
pain  is,  as  a  rule,  more  circumscribed  than  in  either  cystitis  or  ure- 
thritis, and  in  many  eases  more  acute.  Urination  in  fissure  is 
always  followed  by  the  maximum  of  pain,  while  in  cystitis  there  is 
a  slight  sense  of  relief.  In  urethritis  the  greatest  pain  is  experi- 
enced during  the  act  of  urination  ;  it  tiien  subsides  gradually,  and  is 
usually  absent  before  the  next  evacuation  of  the  bladder. 

Dingiiosift. — The  question  of  diagnosis  will  usually  rest  between 
fissure,  urethritis,  and  cystitis.  The  latter  can  be  easily  and  posi- 
tively excluded  by  an  examination  of  the  urine.     Passing  a  catheter 


ORGANIC  DISEASES   OF  THE   URETHRA.  831 

into  the  bladder  and  allowing  a  little  urine  to  liow  tlirou<i:;li  it  will 
wash  away  any  pus  or  mucus  that  may  have  been  caught  up  in  its 
introduction.  The  remaining  urine  should  bo  saved  for  examina- 
tion, when  if  fissure  alone  exist,  it  will  be  found  free  from  all  the 
products  of  cystitis. 

The  exclusion  of  urethritis  and  the  detection  of  fissure  are  ac- 
complished by  the  endoscope,  and  by  the  use  of  this  instrument  a 
correct  diagnosis  can  easily  be  made.  I  have  already  described  the 
method  of  using  my  endoscope,  but  there  are  a  few  points  in  the 
examination  for  fissure  to  which  I  have  yet  to  call  attention.  In 
the  first  place,  the  neck  of  the  bladder  must  be  found  exactly,  and 
to  accomplish  this  the  instrument  must  be  used  when  there  is  at 
least  a  small  quantity  of  urine  in  the  organ.  Then  the  tube  is  to  be 
introduced  far  enough  to  be  sure  that  it  enters  the  bladder.  Next 
the  mirror  is  to  be  passed  in,  and,  when  it  enters  that  part  of  the 
tube  surrounded  by  urine,  it  will  be  seen  that  it  becomes  black,  ijfe., 
the  wall  of  the  urethra  (which  was  reflected  as  the  mirror  was  passed 
in)  disappears,  and  nothing  can  be  seen.  By  slowly  withdrawing 
the  mirror  the  upper  end  of  the  urethra  will  come  into  view,  and 
by  moving  it  backward  and  forward  and  turning  it  round,  the  whole 
circumference  of  the  vesico-urethral  juncture  can  be  clearly  seen, 
and  the  fissure  distinctly  observed. 

The  service  rendered  me  by  this  instrument  in  studying  this 
affection  has  been  very  great.  Indeed,  I  was  never  able  to  detect  a 
vesico-urethral  fissure  until  I  used  this  endoscope  to  look  for  it.  I 
have  tried  repeatedly  to  find  a  fissure  with  the  ordinaiy  open-tube 
endoscope,  and  have  invariably  failed,  and  for  these  reasons  :  Fissure 
lies  in  a  longitudinal  sulcus  of  the  mucous  membrane,  and  is  hidden 
from  view  at  the  upper  or  open  end  of  the  tube.  It  can  only  be 
brought  to  light  by  distending  the  urethra  at  the  point  to  be  ob- 
served, and  that  can  not  be  done  with  the  instrument  in  question. 
Again,  when  the  oj)en  tube  is  carried  up  to  the  neck  of  the  bladder, 
where  the  fissure  is  situated,  the  urine  flows  into  the  tube  and  puts 
a  stop  to  observations. 

The  description  of  the  appearance  of  fissure  already  given  was 
taken  from  my  own  observation  with  the  endoscope,  and,  therefore, 
need  not  be  repeated  here. 

Causation. — The  cause  or  causes  of  fissure  here  are  not  well 
understood.  At  least,  I  have  not  been  able  to  find  anything  in  the 
books  that  is  clear  and  definite  on  the  subject. 

From  a  careful  study  of  the  cases  which  have  come  under  my 
own  observation,  I  am  satisfied  that  fissure  (or  irritable  ulcer)  is 


832  DISEASES   OF   WOMEN. 

developed  from  urethritis,  I  will  suppose  that  a  woman  gets 
urethritis,  from  any  cause,  and  that  it  extends  to  the  neck  of  the 
bladder,  and  dips  down  into  the  folds  of  the  mucous  membrane.  It 
is  easy  to  understand  that  the  pressing  together  of  the  two  iuHamed 
surfaces  of  the  membrane  in  these  folds  will  increase  the  irritation 
and  keep  up  the  disease.  Urine,  mucus,  pus,  and  exfoliated  epithe- 
lium are  liable  to  lodge  in  this  location,  and  add  very  much  to  the 
irritation.  All  this  leads  to  ulceration,  and  when  this  is  established 
it  remains,  with  no  tendency  to  recover.  Even  if  the  parts  were 
inclined  to  heal,  the  irritation  of  the  urine  and  inflammatory  prod- 
ucts, as  well  as  the  contraction  of  the  inflamed  surfaces  upon  each 
other,  would  prevent,  or  at  least  hinder,  recovery. 

It  can  be  seen  that  an  m'ethritis  might  end  promptly  in  recovery 
(either  by  the  natural  tendency  of  mucous  inflammation  to  return  to 
health,  or  under  the  influence  of  treatment),  except  at  the  point  of 
Assure,  where  the  conditions  named  tend  to  produce  ulceration,  and 
when  once  developed,  to  keep  it  up. 

Injuries  during  confinement,  displacements  of  the  bladder,  indeed, 
injuries  of  any  kind  that  are  sufiicient  to  cause  inflammation  at  the 
vesico-urethral  juncture,  doubtless  tend  to  the  establishment  of 
fissure. 

Bungling  or  careless  use  of  the  catheter,  or  injections  into  the 
bladder  or  urethra,  might  have  the  same  evil  effects. 

I  suspect,  but  am  not  quite  sure,  that  very  small  calculi  passing 
along  the  urethra  may  be  a  cause  of  this  trouble.  This  supposition 
is  based  on  a  case  which  occurred  in  my  practice.  Its  history  is 
this.  The  lady  had  a  vesico- vaginal  fistula,  and  after  it  was  closed 
she  had  catarrh  of  the  bladder.  During  the  course  of  that  disea.se 
she  was  taken  with  haemorrhage,  which  lasted  some  days.  She  then 
had  violent  pain  in  urinating,  and  passed  several  lumps  which  were 
composed  of  mucus  and  some  of  the  salts  of  the  urine.  These  pieces 
were  rough,  gritty  masses,  which  no  doubt  scratched  the  urethra  as 
they  passed  out.  Soon  after  this  she  was  found  to  have  a  fissure 
that  tormented  her  to  an  extent  beyond  description.  Dilatation  of 
the  urethra  and  topical  applications  relieved  her. 

Treatment — The  subject  of  the  management  of  vesico-urethral 
fissure  is  one  of  interest  and  importance,  as  much  so  as  anything  in 
surgery.  On  the  one  hand  there  is  the  terrible  suffering  of  the 
patient,  and  on  the  other  there  are  many  difiiculties  to  be  encoun- 
tered in  the  efforts  to  relieve  her.  The  demand  for  treatment  is 
urgent,  and  skill  in  the  highest  degree  is  necessary  to  accomplish  a 
cure. 


ORGANIC   DISEASES   OF   THE   URETHRA.  833 

I  must  first  say  vvliat  ought  not  to  he  done  in  these  cases,  and 
thereby  guard  against  making  them  worse  instead  of  better,  as  it  has 
been  ray  misfortune  to  do  on  more  than  one  occasion.  As  a  rule, 
all  injections  and  instillations  such  as  I  have  recommended  in  cys- 
titis, and  shall  advise  in  urethritis,  do  harm  in  lissure.  I  have  used 
injections  of  mild  solutions  of  nitrate  of  silver,  and  the  application 
of  stronger  solutions  to  the  diseased  part,  with  the  invariable  result 
of  increasing  the  spasmodic  contraction  of  the  bladder  and  aggrava- 
ting the  suffering  of  my  patients. 

While  such  applications  are  useful  in  inflammation  of  the  bladder 
and  urethra  they  do  harm  in  fissure.  This  I  have  repeatedly  proved 
to  my  own  satisfaction,  and  the  facts  accord  with  our  experience  in 
other  departments  of  practice.  Nitrate  of  silver  and  nitric  acid  have 
been  applied  to  ulcerations  of  the  rectum  with  marked  benefit,  and 
without  being  followed  by  pain  of  any  account ;  but  the  same  appli- 
cation made  to  fissure  within  the  grasp  of  the  sphincter  ani  does 
little  if  any  good,  and  usually  increases  the  suffering  of  the  patient. 
The  same  is  true  of  the  fissure  under  discussion.  When  a  diagnosis 
of  vesico-urethral  fissure  has  been  made,  the  usual  local  treatment  is 
not  to  be  employed,  at  least  active  measures  in  the  way  of  powerful 
applications  are  to  be  avoided. 

Soothing  applications,  alterative  in  their  action,  are  worthy  of 
trial  Exposing  the  fissure  with  the  fenestrated  speculum,  and 
dusting  it  over  ^vitll  calomel  or  finely  pulverized  iodoform,  some- 
times give  relief.  Subnitrate  of  bismuth  may  be  used  in  the  same 
way  in  the  hope  of  doing  good.  There  is  one  great  point  to  be 
remembered  in  using  these  remedies,  and  that  is,  that  if  they  fail  to 
accomplish  the  desired  end,  they  do  no  harm. 

I  have  used  with  benefit  the  "mitigated"  stick  of  nitrate  of 
silver.  It  consists  of  one  part  of  nitrate  of  silver  to  two  or  three 
parts  of  the  nitrate  of  potash.  Drawing  a  fine  point  of  this  through 
the  fissure  causes  sharp  pain  at  the  time,  which  is  often  followed  by 
burning,  and  tenesmus,  which,  however,  soon  subside.  In  some 
cases  the  trouble  is  relieved  by  this  treatment. 

Incising  the  fissure,  in  the  manner  that  surgeons  treat  the  same 
disease   of   the   anus, 

has  been  followed  by    /^^^^"'^Z:^^,,,=====^^^^ 
great  relief,  but  I  do 
not  believe  that  I  ever 
cured   a   case  in  this 
way.     For  this  operation  I  use  a  small  knife,  wliich  is  represented 
in  Fig.  241. 
64 


Fig.  241. — Skene's  fissure  probe  and  knife. 


834  DISEASES   OF  WOMEN. 

In  tlie  employment  of  this  local  treatment  great  difficulty  will  be 
found  in  getting  at  the  diseased  spot.  The  fissure  can  easily  be  seen 
through  the  glass  tube  of  the  endoscope,  but  to  expose  it  and  make 
applications  to  it  are  exceedingly  difficult  tasks.  I  have  tried  in  a 
variety  of  ways  to  do  this,  but  have  found  that  the  only  satisfactory 
way  is  by  means  of  the  endoscoj^e,  consisting  of  a  glass  tube,  hard- 
rubber  external  tube,  and  mirror,  which  I  have  fully  described.  This 
combination  of  speculum  and  mirror  answers  very  well  in  a^^plying 
such  remedies  as  bismuth,  calomel,  and  the  like ;  but  it  will  be  found 
that  skill  and  patience  are  required  to  touch  the  fissure  with  the 
nitrate-of-silver  stick,  or  to  incise  the  part  as  already  advised. 

The  method  which  I  employ  is  this :  A  small  silver  probe  is  bent 
into  the  shape  shown  in  the  figure  (Fig.  243),  and  its  point  is  coated 
with  the  material  to  be  used.  It  is  then  introduced  through  the 
speculum  and  drawn  slowly  through  the  fissure  so  as  to  produce 
superficial  cauterization  of  the  ulcerated  part.  The  point  of  the 
probe  is  coated  by  melting  the  "  mitigated  "  stick  of  nitrate  of  silver 
in  a  platinum  cup,  into  which  the  probe  is  dipped  and  the  coating 
allowed  to  cool.  The  dipping  may  be  repeated  as  often  as  is  neces- 
sary to  get  the  required  amount  of  caustic  or  coating  on  the  probe. 

Before  applying  the  caustic,  any  mucns  or  serum  that  may  be  in 
or  about  the  fissure  must  be  sponged  away.  This  may  be  done  by 
wrapjDing  a  piece  of  absorbent  cotton  on  the  end  of  a  probe,  and 
using  it  as  a  sponge. 

It  will  be  observed  that  I  condemned  caustics  in  the  treatment 
of  fissure,  and  still  advise  cauterizing  the  diseased  part  with  nitrate 
of  silver.  The  point  is  simply  this,  that  caustics  applied  by  injec- 
tion to  the  neck  of  the  bladder  in  which  there  is  fissure  do  harm, 
but  caustic  appHed  to  the  fissure  only,  does  good. 

I  have  observed  that  pain  follows  the  application  of  caustics,  but 
if  the  diseased  portion  and  nothing  more  is  thoroughly  touched,  re- 
lief follows.  The  old  trouble  and  pain  are,  however,  liable  to  return 
in  time.  The  same  may  be  said  of  incision,  viz.,  that  relief  is  but 
temporary.  I  think  that  the  bleeding  which  is  caused  relieves  irri- 
tation and  congestion  for  a  time,  but  I  can  not  say  that  I  have  ever 
seen  a  permanent  cure  follow  this  treatment,  except  in  a  few  cases, 
where  the  treatment  was  begun  early  in  the  course  of  the  disease. 

I  come  now  to  dilatation  of  the  urethra  as  a  means  of  relieving 
fissure.  Although  I  have  left  this  measure  until  the  last,  it  is  really 
the  first  in  importance  in  the  treatment  of  this  affection.  Indeed, 
I  am  inclined  to  think  that  it  is  of  much  more  value  in  the  treat- 
ment of  fissure  than  in  that  of  either  cystitis  or  urethritis. 


OEGANIC  DISEASES   OF  THE  URETHRA.  835 

I  Lave  already  sounded  a  note  of  warning  against  the  two  great 
dangers  of  dilating  the  urethra — viz.,  rupture  and  incontinence,  and 
incontinence  without  rupture.  Both  accidents  are  liable  to  occur  in 
dilating  the  urethra,  but  they  only  occur  when  the  dilatation  is 
carried  to  a  great  extent,  sufficient  at  least,  to  admit  the  ordinary 
sized  index-finger.  This  extreme  dilatation  is  not  necessary  in  the 
treatment  of  iissure.  I  generally  ascertain  what  sized  sound  can  be 
passed  with  ease,  and  then  dilate  sufficiently  to  admit  one  three 
or  four  sizes  larger.     This  is  usually  all  that  is  necessary. 

Before  dilating  it  must  be  seen  that  the  urine  is  normal  in  char- 
acter, or  as  nearly  so  as  can  be  made  by  general  treatment.  Then 
the  urethra  is  to  be  dilated,  the  patient  being  kept  at  rest,  and  the 
urine  made  as  bland  as  possible  with  diluent  drinks. 

In  case  that  incontinence  should  follow  (though  I  presume  that 
will  not  occur),  its  treatment  should  at  once  be  commenced  by  sup- 
porting the  urethra  in  the  way  that  I  have  advised,  viz.,  with  the 
pessary  for  that  purpose.  I  believe  that,  if  taken  in  hand  within 
three  or  four  days  after  it  occurs,  the  incontinence  can  be  relieved. 

Should  the  treatment  that  I  have  thus  far  recommended  fail, 
then  a  vesico-vaginal  fistula  should  be  made,  the  bladder  and  urethra 
washed  out  regularly,  and  if  need  be  medicated.  The  fistula  may 
be  allowed  to  close  of  its  own  accord,  as  it  usually  will  do.  By  the 
time  the  fistula  closes,  the  fissure  will  have  healed.  In  making  a 
vesico-vaginal  fistula  to  cure  fissure,  the  knife  or  scissors  should  be 
used,  and  not  the  cautery ;  because  it  is  not  necessary  to  maintain 
the  opening  in  the  bladder  for  a  very  long  time  ;  and  if  it  closes  of 
its  own  accord,  a  very  important  operation  is  avoided. 

4.  Neoplasms  of  the  Urethra. — A  knowledge  of  urethral  neo- 
plasms is  by  no  means  confined  to  recent  times,  but  up  to  a  late 
date  they  have  not  been  studied  as  closely  as  they  deserve  to  be,  nor 
classified  in  a  comprehensive  and  scientific  manner.  The  various 
tumors  have  frequently  been  confounded  with  one  another  by 
authors  and  observers,  and  much  confusion  and  obscure  statement 
have  resulted  in  regard  to  their  symptomatology,  pathology,  and 
treatment. 

These  growths  have  been  variously  known  as  carunculse,  cellulo- 
vascular  tumors,  fleshy  and  vascular  growths,  fungoid  excrescences, 
strawberry  and  raspberry  tumors,  each  name  sometimes  having 
been  used  to  cover  the  whole  class. 

Winckel's  division  and  classification  are  most  excellent,  and  to 
some  extent  I  shall  follow  them  in  the  consideration  of  the  subject. 
I  will  classify  these  tumors  as  follows : 


836  DISEASES   OF  WOMEN. 

Papillary. — Condjloraa. 

Glandular. — Cysts,  mjxo-adeiioma,  mucous  polypi. 

Yascular. — Angioma,  varices,  phlebectases. 

Areolar  Connective  Tissue. — Fibroma,  sarcoma. 

Epithelial. — Epithelioma,  carcinoma. 

Compound. — Papillary  polypoid  angioma,  erectile  tumors. 

Neoplasms  of  tlie  urethra  are  more  common  in  the  female  than 
in  the  male,  and,  of  course,  easier  of  diagnosis  and  treatment. 

Papillary  Neoplasms. — Under  the  first  head,  or  that  of  papillary 
neoplasms,  will  be  seen  condyloma,  a  growth  of  a  low  grade,  and  of 
a  warty  appearance.  The  surface  may  be  bright  red,  or  partially 
white,  from  epithelial  aggregation.  These  growths  are  painless,  and 
do  not  bleed  on  touch  or  manipulation.  They  may  or  may  not  be 
pedunculated.  They  may  occur  singly  or  in  clusters,  and  be  wholly 
within  the  urethra  or  projecting  from  the  meatus. 

They  consist  of  somewhat  dilated  capillaries  set  in  a  tough  homo- 
geneous network  of  connective  tissue,  the  whole  having  a  thin  epi- 
thelial covering,  that  may  at  times  be  increased  by  an  unusually 
rapid  epithelial  proliferation.  This  only  occurs  when  the  tumors 
are  much  irritated. 

Glandular  Neoplasms. — Cysts  of  the  female  urethra  are  not  com- 
mon, and  are  not  confined  to  any  period  of  life,  having  been  found 
in  a  foetus  of  from  six  to  seven  months  and  in  all  subsequent  periods 
of  hf  e. 

They  are  in  early  age  situated  in  the  anterior  or  meatal  portion 
of  the  urethra,  but  later  in  life  nearer  the  vesical  neck.  They  may 
or  may  not  j^i'oject  from  the  urethra ;  however,  they  cause  a  greater 
or  less  obstniction  to  the  free  outfiow  of  urine.  They  are  usually 
formed  by  the  occlusion  of  the  orifice  of  the  small  urethral  ducts 
or  glands,  and,  in  some  cases,  a  black  speck  upon  the  surface  of  the 
cyst  indicates  the  seat  of  the  former  orifice. 

By  bagging  of  the  mucous  membrane  and  absorption  of  the  con- 
tents, these  small  cysts  may  be  transformed  into  polypi. 

Winckel  says  that  the  internal  wall  of  the  cyst  usually  shows 
numerous  small  papillae,  and  is  lined  with  pavement  epithelial  scales. 

Myxo-adenoma  are  quite  rare.  They  are  small  (the  largest  being 
seldom  larger  than  a  small  hazel-nut),  of  a  bright  scarlet  color,  and 
quite  vascular.  They  consist  of  a  number  of  vessels  set  in  partly 
destroyed  gland  tissue,  and  small  meshes  containing  myxomatous 
matter.  The  whole  is  contained  in  the  meshes  of  a  soft,  loose  con- 
nective tissue. 

Polypi  coming  under  this  head  are  those  formed  by  occlusion  of 


OEGANIO  DISEASES  OF  THE   UEETHRA.  837 

tlie  orifices  of  one  or  more  of  the  ducts  or  follicles  of  the  urethra. 
The  other  forms  of  polypi  will  be  considered  under  their  proper 
head. 

Vascular  K'eoplasms. — Angioma,  varices,  and  phlebectases  are 
really  different  names  for  about  the  same  condition — viz.,  an  increase 
in  the  caliber  of  the  veins  and  venous  radicles,  allowing  an  overdis- 
tention,  at  first  intermittent,  and  later  chronic.  They  appear  as 
bunches  or  bundles  of  worm-like,  irregularly  distended  dark  blue 
or  bluish  red  vessels.  There  is  more  or  less  thickening  of  the  mucous 
membrane  and  connective  tissue  about  them ;  they  are,  in  fact,  in 
all  respects  analogous  to  rectal  hsemorrhoids.  They  may  occupy  any 
part  of  the  urethra,  but  usually  select  the  floor  of  the  canal.  The 
trouble  they  cause  depends  on  their  size.  If  large,  they  obstruct  the 
urethra.  Sometimes  the  vessels  rupture,  and  the  blood  is  poured  out 
beneath  the  mucous  membrane.  Tumors  resulting  from  rupture  of 
such  varices  under  a  normal  mucous  membrane  have  been  known  to 
some  authors  under  the  name  of  hsematoma  polyposurd  urethra, 
which  describes  very  well  the  condition  resulting. 

Some  of  these  vascular  tumors  have  been  found  to  be  erectile, 
the  anatomical  peculiarities  of  which  structure  are  already  familiar. 

Yirchow  believes  these  tumors  to  be  a  combination  of  urethral 
hsemorrhoids  and  remnants  of  embryonal  duplicity  of  the  vagina. 

Areolar  Neoplasms. — These  new  growths  are  either  fibromata  or 
sarcomata. 

The  fibromata  may  lie  within  the  canal  of  the  urethra  or  be  im- 
bedded in  its  walls.  When  "in  the  urethra  or  protruding  from  the 
meatus,  they  are  pedunculated,  and  have  been  known  as  urethral 
polypi.  They  vary  in  size  from  that  of  a  pea  to  that  of  a  goose-egg. 
They  consist  of  numerous  densely  packed  fibers,  that  give  the  same 
appearances  as  fibromata  elsewhere. 

They  have  been  found  in  several  cases  at  birth,  but  are  of  rare 
occurrence  at  any  age.  When  congenital,  they  have  been  known  as 
congenital  polypoid  excrescences.  The  tumors  are  usually  covered 
with  several  layers  of  pavement  epithelium. 

Sarcoma  of  the  urethra  is  an  extremely  rare  affection,  but  one  or 
two  cases  being  on  record.  One  case  observed  by  Beigel  is  described 
by  Winekel.  It  was  trilobed,  about  the  size  of  a  walnut,  and  was 
situated  about  the  edge  of  the  external  meatus.  It  was  in  part  hard, 
in  part  soft,  the  harder  portion  consisting  of  a  fine  fibrous  network, 
the  interstices  of  which  were  filled  with  small  cells.  In  some  places 
the  cells  were  absent  and  the  stroma  more  dense,  and  in  the  pe- 
ripheral parts  the  network,  while  coarser,  was  firm,  and  presented 


838  DISEASES  OF  WOMEN". 

cavities  filled  with  a  colloid  material.  The  tumor  was  extirpated, 
but  nothing  is  said  about  its  retm*n. 

Epithelial  Neoplasms. — The  existence  of  cancerous  disease  of  the 
female  urethra  as  a  primary  affection  is  greatly  doubted  by  many 
authors,  but  it  probably  does  occasionally  occur.  Indeed,  as  a  sec- 
ondary disease,  it  is  quite  rare,  for,  when  extending  from  the  uterus 
or  neighboring  organs  to  the  bladder,  death,  as  a  rule,  results  before 
the  urethra  is  involved.  In  cases  where  life  is  unusually  prolonged, 
the  disease  seldom  attacks  more  than  the  vesical  portion  of  the  canal. 

Extension  from  the  outer  genitals,  which  are  very  rarely  affected 
with  cancerous  disease,  is  still  more  uncommon,  and  possibly  has 
never  occurred.  One  case  is  recorded,  however,  in  a  woman  who 
had  long  suffered  from  uterine  prolapse,  where  a  tumor,  which  de- 
pended from  the  frseniculum  clitoridis,  had  invaded  the  meatus 
urinarius.  Under  the  microscope  it  proved  to  be  a  flat-celled  epi- 
thelio-cancroid. 

We  have  the  record  of  cases  of  periurethral  cancer  that  ap- 
peared at  the  introitus  vulvae  near  the  meatus,  and  in  the  connective 
tissue  about  the  urethra,  as  small,  hard,  painless  tubercles,  the  ure- 
thra or  its  membrane  not  being  involved. 

Symptomatology. — Pain  is  the  exception  rather  than  the  rule  in 
this  affection ;  but  in  some  instances  acute,  lancinating  pains  are  pres- 
ent. At  first  the  tubercles  are  small,  hard,  and  usually  painless,  but 
after  a  time  they  soften,  ulcerate,  and  bleed  freely.  The  vesti- 
bule and  urethral  mucous  membrane  are  usually  involved  in  the 
mischief. 

The  affection  has  been  divided  into  three  grades,  in  the  first  of 
which,  according  to  Winckel,  "  but  half  the  length  and  depth  of  the 
urethra  is  invaded  by  the  cancerous  tubercles ;  in  the  second  the 
vesical  neck  and  pelvic  fascia;  and  in  the  third  the  pubic  sym- 
physis, descending  pubic  rami,  and  the  closely  blended  connective 
tissue  are  involved." 

Compound  Neoplasms. — The  most  common,  and  consequently  the 
most  interesting  form  of  urethral  neoplasm,  is  the  papillary  polypoid 
angioma. 

These  tumors  vary  in  size  from  a  pin-head  to  a  hickory-nut,  and 
may  be  either  multiple  or  single,  but  are  usually  single.  They  vary 
in  color  from  a  pale  to  a  bright  red,  and  may  or  may  not  be  pedun- 
culated. Their  favorite  seat  is  on  the  posterior  wall  of  the  lower 
half  of  the  urethra,  very  near  to  or  at  the  meatus.  This  neoplasm 
is  generally  known  as  urethral  caruncle,  or  vascular  tumor  of  the 
urethra,  and  is  described  very  fully  in  most  of  the  books  on  diseases 


ORGANIC  DISEASES  OF  THE  URETHRA.  839 

of  women.  Indeed,  it  is  tlie  only  abnormal  growth  of  the  female 
urethra  that  I  ever  read  or  heard  of  in  my  student  days.  There  is 
really  not  mnch  difference  between  this  form  of  neoplasm  and  the 
vascular  tumor  of  the  urethra  already  described,  and  what  is  far  more 
important  both  of  these  neoplasms  have  been  confounded  with  hyper- 
plasia of  the  tissues  around  the  mouths  of  the  ducts  of  the  urethral 
glands.  This  condition  will  be  discussed  under  the  head  of  diseases 
of  the  urethral  glands.  There  are  very  good  reasons  why  this  affection 
should  have  claimed  early  attention  from  gynecologists.  It  occurs 
frequently,  and  nearly  always  causes  great  suffering,  and  is  easily 
detected,  because  it  grows  at  the  meatus  urinarius,  where  it  can  be 
seen. 

It  consists  of  bunches  of  dilated  capillaries  set  in  a  moderately 
dense  stroma  of  connective  tissue,  and  covered  with  mucous  mem- 
brane, which  has  the  usual  pavement  epithelium.  One  case,  however, 
is  recorded  where  the  pavement  was  replaced  by  columnar  epithe- 
lium. The  vessels  are  greatly  dilated,  and  in  some  cases  very  tor- 
tuous ;  in  others  much  less  so. 

In  some  cases  these  tumors  partake  of  the  erecj:ile  character, 
being  markedly  increased  in  size  at  the  menstrual  period,  and  at 
other  times. 

Occasionally  small  tumors  of  this  kind  are  found  singly  in  the 
vestibule.  As  a  rule  they  bleed  very  easily  on  touch,  and  are  ex- 
quisitely sensitive.  Observers  differ  as  to  whether  the  nerve  supply 
to  the  tumor  is  marked,  some  claiming  to  find  a  large  nerve  distri- 
bution, others  to  find  none.  As  they  are  exceedingly  tender,  the 
inference  may  be  drawn  that  they  are  well  supplied  with  nerves. 

Symptomatology. — Unless  the  tumors  be  of  large  size  the  patient 
may  go  on  for  a  long  period  without  experiencing  anything  more 
than  a  slightly  irritable  condition  of  the  urethra.  When,  however, 
the  tumors  become  large,  or  are  of  the  polypoid  angioma  variety,  the 
pain  is  markedly  increased,  and  the  obstruction  to  the  outflow  of 
urine  becomes  very  apparent.  These  tumors,  by  constant  moisture 
and  friction,  become  eroded  on  their  surface,  and  these  ulcerations, 
being  constantly  aggravated,  give  rise  usually  to  slight  hemorrhage 
and  increased  pain.  Ketention  of  urine  may  result  from  their  clos- 
ing the  urethra. 

Of  all  the  urethral  neoplasms,  however,  the  papillary  polypoid 
angiomata  are  the  most  intensely  painful,  and  patients  retain  their 
water  for  a  long  time  to  avoid  the  agony  that  is  produced  by  passing 
it.  The  pain  is,  in  some  cases,  present  at  all  times,  and  is  greatly 
aggravated  by  sitting  or  lying  down.     The  clothes  coming  in  con- 


840  DISEASES   OF   WOMEK 

tact  witli  the  exquisitely  sensitive  surface  often  produce  vaginal  and 
anal  spasm.  Coition  is  sometimes  impossible.  A  case  is  related  of 
an  old  woman  tlius  aifected,  who,  though  mariied  some  thirty  years, 
was  still  a  virgin.  Indeed,  this  affection  is  sometimes  mistaken  for 
vaginismus,  and  treated  accordingly.  The  directions  which  I  shall 
give  under  the  head  of  diagnosis  will,  I  think,  be  sufficiently  plain 
to  prevent  such  mistakes. 

Even  when  these  tumors  are  too  small  to  obstruct  the  urethra, 
obstruction  may  occur  from  severe  spasm  due  to  the  pain  caused  in 
the  act  of  micturition. 

Bleeding  from  these  tumors  is  not  uncommon,  hut  it  seldom 
amounts  to  much,  and  is  easily  controlled. 

The  pain  in  any  of  these  new  growths  is  not  always  confined  to 
the  urethra,  but  may  be  felt  in  the  back,  hips,  suprapubic  region, 
thighs,  knees,  and  feet.  In  carcinoma  lancinating  pains  may  be 
present,  but  this  is  by  no  means  the  rule. 

As  the  tumors  increase  in  size,  the  urethra  becomes  gradually 
dilated,  and  the  mucous  membrane  eroded,  hypersemic,  and  catarrhal. 
Its  structure  may  become  loose,  flabby,  and  vascular,  and  a  pouch 
form  behind  the  tumor.  If  far  enough  back  to  interfere  with  per- 
fect closure  of  the  vesical  neck,  incontinence  may  occur,  and  incon- 
venience and  distress  the  patient  greatly. 

Sometimes  the  bleeding  is  severe,  and  the  patient  suffers  from 
anaemia  caused  thereby.  This  is  more  usually  the  case  if,  in  the  de- 
structive process  attending  carcinoma,  an  artery  of  any  considerable 
size  is  opened  into.     This  accident,  however,  rarely  occurs. 

In  the  extremely  painful  neoplasms,  the  face  gives  evidence  of 
constant  pain,  distress,  and  anxiety ;  and  in  the  most  aggravated 
forms  patients  are  pale,  emaciated,  and  extremely  low-spirited,  often 
wishing  earnestly  for  death  to  relieve  their  sufferings. 

If  the  tumor  be  of  sufficient  size  to  be  a  serious  bar  to  free  mic- 
turition, cystitis,  pyelitis,  and  more  serious  results,  as  renal  destruc- 
tion, are  to  be  feared. 

The  presence  of  small,  and  even  large  tumors,  in  the  urethra 
and  about  the  meatus  often  gives  rise  to  increased  sexual  desire,  that 
is  gratified  in  the  young  girl  by  masturbation. 

The  urine  is  normal,  save  that  it  contains  the  products  of  urethral 
disease,  viz.,  epithelium,  pus,  mucus,  and  sometimes  blood.  Small 
pieces  of  the  tumor,  small  cysts  or  polypi,  the  pedicles  of  which 
have  died  or  been  torn  through,  are  sometimes  found  in  the  urine. 

In  cancerous  neoplasms,  as  the  disease  invades  the  tissues  to  the 
second  and  third  degrees  mentioned  in  connection  with  malignant 


ORGANIC  DISEASES   OF  THE  URETHRA.  841 

tubercle,  the  patients  gradually  sink  and  die  from  exhaustion  from 
severe  bleedings,  loss  of  rest,  and  general  cachexia.  Some  cases, 
however,  do  not  succumb  until  long  after  the  third  degree  has  been 
reached,  with  extensive  destruction  of  tissue. 

Diagnosis. — The  diagnosis  of  urethral  neoplasm  is  reallv  quite 
easy,  provided  the  investigation  is  thoroughly  and  intelligently  con- 
ducted. When  a  woman  comes  to  the  physician  comjolaining  of 
pain  on  micturition,  pain  in  sitting,  obstructions  to  or  interruptions 
in  the  flow  of  urine  he  should  at  once  proceed  to  a  thorough  investi- 
gation of  the  parts,  first  by  the  eye  and  touch,  and  second  by  the 
aid  of  the  speculum,  endoscope,  and  an  examination  of  the  urine. 
If  the  tumor  presents  at  the  meatus,  it  will,  of  course,  be  readily 
seen,  and  can  be  easily  diagnosticated. 

If  in  the  urethra,  the  finger  passed  along  the  course  of  the  ure- 
thra in  the  vagina,  with  some  dilatation  of  the  meatus,  will  discover 
it.  If  of  small  size,  the  endoscope,  with  a  strong  light,  will  give  an 
excellent  view  of  it.  If  the  tumor  be  exquisitely  sensitive,  as 
some  are,  the  patient  should  be  wholly  or  partially  anaesthetized,  and 
then  the  examination  can  be  fully  and  freely  made.  Yaginismus 
may  be  excluded  by  passing  the  finger  into  the  vagina,  away  from 
the  urethra,  when  no  spasm  will  take  place ;  but  if  the  urethra  is 
touched,  the  spasm  is  at  once  produced. 

To  determine  whether  the  inflammatory  mischief,  when  it  exists, 
resides  in  the  urethra  alone,  the  patient  should  be  directed  to  pass 
one  half  of  her  urine  into  one  vessel,  and  the  other  into  another.  If 
the  trouble  is  seated  in  the  urethra  only,  the  last  urine  passed  will  be 
totally  or  almost  wholly  free  from  the  inflammatory  products.  The 
same  may  be  accomplished  also  by  drawing  off  the  urine  with  a 
clean  catheter. 

In  some  cases  the  varicose  condition  of  the  vessels  of  the  nmcous 
membrane,  with  considerable  swelling,  may  simulate  prolapse  of  the 
mucous  membrane.  If,  however,  the  blue  discoloration  is  borne  in 
mind  together  with  the  elastic  feel,  and  the  reduction  in  size  under 
compression  of  the  urethral  hsemorrhoids,  there  will  seldom  be  any 
error  in  the  diagnosis.  Of  course,  prolapse  of  the  mucous  membrane 
and  a  varicose  condition  of  the  urethral  veins  sometimes  coexist,  and 
this  must  not  be  forgotten. 

Tumors,  usually  those  of  large  size  and  pedunculated,  often  cause 
some  degree  of  prolapse  of  the  mucous  membrane  by  constant  drag- 
ging. A  prolapsus  of  the  mucous  membrane  may  also  simulate  a 
tumor.  The  position  of  the  meatal  orifice,  and  the  fact  that  it  can 
be  reduced,  will  distinguish  the  prolapse. 


84:2  DISEASES  OE   WOMEK 

To  distinguisli  one  kind  of  tumor  from  another  is  not  always 
easy,  but  with  a  little  care  it  can  be  accomplished.  The  condyloma 
will  be  recognized  by  its  painlessness,  its  warty,  cracked,  pinkish 
white  or  white  surface,  and  the  fact  that  similar  growths  are  at  the 
same  time  usually  found  on  the  vestibule.  The  polj^poid  angioma 
will  be  known  by  its  bright-red  surface,  its  tendency  to  bleed 
easily,  and  the  exquisite  pain  produced  when  touched.  The  sar- 
coma will  be  readily  confounded  with  the  angioma,  but  it  is  very 
rarely  found  here ;  and  if  there  is  any  doubt,  a  little  piece  may 
be  scraped  off  with  the  curette,  and  examined  microscopically. 
Should  doubt  still  remain,  the  history  and  progress  of  the  disease 
will  soon  determine  the  nature  of  the  trouble.  The  malignant  tumor 
will  grow  much  faster  than  the  other.  The  varices  can  be  told  by 
their  bluish  color  and  their  shrinking  under  pressure,  and  the  cysts 
and  fibromata  by  their  smooth,  painless  surface,  normal  mucous  cov- 
ering, and  their  consistence. 

Carcinoma  appears,  as  I  have  already  said,  as  hard  tubercles 
(usually  periurethral),  which  after  a  time  ])reak  down.  When  this 
occurs,  the  endoscope,  the  lancinating  pains  (if  present),  the  rapid 
invasion  of  neighboring  tissue,  and  the  composition  of  the  diseased 
mass,  under  the  microscope,  will  tell  the  story. 

Prognosis. — The  simple  forms  of  urethral  tumor  are  easily 
removed,  and  do  not  return.  As  a  rule,  therefore,  the  prognosis 
is  good.  Of  this  class  are  cysts,  condylomata,  mucous  polypi,  and 
fibromata. 

The  angiomas  are  of  a  more  serious  nature,  as  by  the  pain  and 
suffering  which  they  cause  the  constitutional  condition  is  usually  low ; 
and,  though  they  may  be  extirpated,  they  are  likely  to  return  and 
rapidly  increase  in  size,  even  in  from  one  to  three  months'  time. 
Although  the  bleeding  from  these  tumors  is  rarely  very  great,  still 
there  may  be  numerous  small  hsemorrhages,  and  at  times  severe 
ones,  either  from  the  urethra  externally  or  into  the  bladder.  Under 
proper  treatment,  however,  there  is  always  a  possibihty,  and  in  some 
cases,  a  certainty  of  cure. 

In  carcinoma  there  is  no  hope  of  effecting  a  cure,  although  the 
patient's  condition  may  be  much  improved  in  some  cases.  Death 
usually  ensues  before  the  third  degree  is  reached.  Almost  the  same 
may  be  said  of  epithelioma,  unless  it  is  treated  in  its  early  stages. 

Causation. — The  causes  of  the  various  neoplasms  are  not  yet 
clearly  made  out,  and  will  not  be,  I  think,  until  more  extended  ob- 
servations are  made  on  the  subject.  Even  then  it  is  more  than 
probable  that  some  of  them  will  remain  obscure. 


ORGANIC   DISEASES   OF   THE   URETHRA.  843 

The  predisposing  causes  are  a  laxity  of  the  urethral  tissues,  with 
a  tendency  to  a  varicose  condition  of  the  parts,  usually  found  in  old 
age ;  a  general  tendency  to  venous  stagnation,  catarrh  of  the  mucous 
membrane,  and  dislocation  of  the  urethra,  partial  or  complete. 

As  a  proof  that  no  single  special  cause  produces  these  condi- 
tions, it  may  be  said  that  these  growths  have  been  found  congeni- 
tally,  and  at  every  period  during  life,  as  late  indeed  as  the  ninety-sec- 
ond year. 

The  exciting  causes,  as  given  by  different  authors,  vary.  The 
following  are  some  of  those  usually  mentioned  : 

1.  Temporary  or  chronic  congestion  of  the  urethra  during  preg- 
nancy, uterine  and  ovarian  tumors,  and  obstructed  portal  circulation. 

2.  Injuries  to  the  parts  during  labor,  external  violence,  the  irri- 
tation of  chronic  and  acute  urethritis  (specific  or  simple),  syphilitic 
poison,  and  masturbation. 

Of  course,  the  carcinoinata,  cysts,  and  simple  mucous  polypi,  are 
not  here  included,  although  some  of  the  above  causes  might  aggra- 
vate if  not  produce  them,  for  I  have  already  spoken  of  their  method 
of  causation  as  far  as  it  is  known.  Cancer  occurs  by  extension  of  the 
disease  from  other  parts ;  cysts  and  mucous  polypi,  from  occluded 
duct  orifices.  This  narrows  the  list  to  the  nervous  class  and  the 
compound,  viz.,  the  polypoid  angiomas.  And  of  these  I  may  vent- 
ure to  say  that  any  cause,  such  as  constant  irritation,  sudden  injury, 
or  slow  congestion,  may  produce  these  conditions,  especially  in 
those  who  are  somewhat  predisposed ;  but  that  any  one  cause,  such 
as  the  gonorrhoeal  poison,  is  sufficient  to  produce  them,  in  all  cases, 
is  more  than  doubtful. 

Most  of  these  tumors  occur  in  married  women,  both  in  those 
who  have  borne  children  and  in  those  who  have  not. 

It  might  be  supposed  from  all  that  has  been  said  upon  this  sub- 
ject that  urethral  neoplasms  are  very  common.  On  the  contrary, 
they  are  very  rare,  with  the  exception  of  polypoid  angiomas. 

Treatment.— Th-Q  treatment  of  these  cases  is,  in  most  instances, 
entirely  surgical,  but  when  the  general  system  is  deranged  in  any 
way  it  should  receive  careful  attention.  If  there  is  a  congested 
condition  of  the  urethra,  the  portal  circulation  should  be  kept  in  a 
normal  state  by  securing  a  healthy  action  of  the  liver  and  bowels. 
The  condition  of  the  circulation  in  the  part  involved  may  ]30ssibly 
be  influenced  by  constitutional  medication.  For  this  purpose, 
ergot,  digitalis,  and  nux  vomica,  in  small  doses  regularly  repeated, 
may  be  of  service.  These  remedies  will  at  least  aid  in  securing  a 
good  general  circulation,  and  may  influence  favorably  the  local  affec- 


844: 


DISEASES   OF  WOMEX. 


Fig.  242. — Skene's  urethral  speculum. 


tion.  If  there  is  local  congestion  due  to  pressure  on  the  pelvic  ves- 
sels, the  cause,  interfering  with  the  return  circulation,  should  be 
removed,  or  remedied,  if  possible. 

The  local  treatment  recommended  by  the  various  authors  differs 
widely,  but  has  the  same  end  in  view,  viz.,  destruction  or  removal 
of  the  abnormal  growth.  The  various  methods  of  extirpation  em- 
ployed are  ligation,  torsion,  excision  by  the  knife,  scissors,  curette, 
ecraseur,  galvano-cautery,  caustics,  and  electrolysis.  Any  one  of 
these  methods  may  be  made  to  answer  in  all  cases,  but  a  judicious 
selection,  according  to  the  location  and  nature  of  the  neoplasm,  is 
advisable.  A  combination  of  means  is  best  at  times,  as,  for  in- 
stance, excision  by  the  scissors  and  cauterization  afterward. 

Whatever  method  may  be  chosen  the  patient  should  first  be 
placed  in  the  lithotomy  or  in  Sims's  position,  on  the  left  side,  which 
I  prefer,  and  the  part  to  be  removed  exposed  by  a  speculum. 

There  are  two  instruments  which  I  use  for  this  purpose.     The 

first  is  here  shown,  Fig. 
242.  It  is  made  on  the 
principle  of  Sims's  specu- 
lum, the  ends  being  of  dif- 
ferent sizes.  An  elevator 
is  attached  at  the  central  portion  between  the  blades,  and  so  arranged 
that  when  it  is  closed  on  one  blade  it  is  thrown  out  from  the  othei-. 
This  is  seen  in  the  figure.  The  elevator  is  pressed  down  on  the 
blade,  and  the  instrument  introduced,  and  then  by  pressing  on  the 
other  end  of  the  elevator  the  urethra  is  distended  to  its  full  natural 
capacity.  When  it  is  necessary  to  expose  one  side  of  the  urethra 
completely,  the  elevator  should  be  removed,  and  the  instrument  used 
in  the  same  way  that  Sims's  speculum  is  em- 
ployed in  the  examination  of  the  vagina. 

The  other  instrument  is  a  modification  of 
Folsom's  nasal  speculum,  made  of  wire,  Fig. 
243.  By  turning  the  nut-screw  the  blades  are 
closed,  and  the  instrument  is  introduced ;  and 
by  unscrewing  it  the  elasticity  of  the  handle 
throws  the  blades  apart.  This  instrument  an- 
swers well  when  the  tumor  to  be  removed  is 
small,  and  we  are  obliged  to  operate  without  as- 
sistance. It  is  self-retaining.  The  other  spec- 
ulum is  preferable  in  most  cases,  but,  in  operat- 
ing through  it,  it  is  requisite  that  some  one  should  hold  it. 

When  the  tumor  is  at  or  near  the  meatus,  and  has  a  large  base, 


Fig.  243.— Skene's  modi- 
fication of  Folsom's 
nasal  speculum. 


ORGANIC  DISEASES   OF  THE   URETHRA. 


845 


or  if  it  is  vascular  and  troublesome  haemorrhage  is  feared,  removal 
bj  ligature  is  preferable.  Having  exposed  the  part  with  the  specu- 
lum the  base  of  the  tumor  is  to  be  transfixed  by  passing  a  needle 
from  without  inward,  parallel  to  the  axis  of  the  urethra ;  a  ligature 
is  then  to  be  passed  around  under  the  needle,  then  the  tumor  is 
grasped  with  a  forceps,  and  traction  made  so  as  to  bring  the  sides  of 
the  base  within  the  grasp  of  the  ligature,  which  should  then  be  tied 
slowly  and  as  tightly  as  possible  without  cutting  the  tissues.  By 
taking  all  these  precautions  the  ligature  will  be  certain  to  include 
all  the  abnormal  tissue,  a  very  important  result  indeed.  If  the  base 
of  the  growth  is  too  large  to  be  included  easily  in  one  ligature, 
transfixion  may  be  made  with  a  needle  armed  with  a  double  thread, 
and  its  two  halves  tied. 

In  choosing  the  material  for  a  ligature,  I  would  advise  the  use 
of  fine  plaited  silk,  boiled  in  a  mixture  of  beeswax,  carbolic  and 
salicylic  acids.  A  ligature  prepared  in  this  way  ties  easily,  does  not 
stick  like  the  ordinary  ligature,  and,  more  than  that,  it  does  not  slip. 

If  the  tumor  is  within  easy  reach  and  is  pedunculated,  the  pedi- 
cle can  be  seized  with  a  small  forceps,  and  the  tumor  grasped  in  a 
polypus-forceps,  and  removed  by  torsion.  Or  it  can  be  cut  off  with 
the  knife  or  scissors,  and,  if  the  pedicle  inclines  to  bleed,  touched 
with  caustic.  Allen's  polypus-forceps  for  the  ear  will  be  found  one 
of  the  most  conven- 
ient instruments  for 
taking  hold  of  these 
little  tumors,  Fig. 
244. 

In  cases  where 
there  are  several 
small  growths  high 
up  in  the  urethra, 
they  can  be  removed 
with  the  curette,  and, 
when  the  hseraor- 
rhage  has  subsided, 
the  base  of  each 
should  be  cauterized. 

But  little  difficul- 
ty will  be  experienced  in  operating  in  the  various  ways  described 
when  the  neoplasms  are  low  down  in  the  urethra,  where  they  can  be 
easily  seen  and  handled.  When  they  are  high  up  in  the  canal,  then 
great  skill  and  care  are  required  to  remove  them.     In  such  cases 


Fig.  244. — Allen's  polypus  forceps. 


846  DISEASES   OF   WOMEN. 

success  will  be  best  obtained  witb  tbe  ecrasem-,  or  the  instrument 
known  as  Blake's  polypus-snare,  used  for  removing  polypi  from  the 
ear,  Fig.  2J:5.     It  is  simply  a  very  delicate  ecraseur,  the  chain  or 

wire  of  which  is 
i'^  1^1  '  ■  Jl.,.  tightened    by  the 

finger  in  place  of 
a  screw.  It  will 
be  found  that,  in- 
stead of  the  wire 

,  ,      ,  commonly      used, 

Fig.  245. — Blake's  polypus  snare.  ''  . 

the  steel  -  wire 
string  of  the  zither  is  better ;  it  is  stronger,  more  elastic  and  pliable, 
yet  stiff  enough  to  be  manageable.  Dr.  John  W.  S.  Gouley,  of  ]^ew 
York,  was  the  first  to  use  this  instrument  for  removing  tumors  of 
the  urethra,  and  I  can  testify  to  its  great  value  in  such  operations. 

In  operating  with  the  snare,  the  tumor  is  exposed  with  the 
urethral  speculum  ;  and,  if  the  growth  is  pedunculated,  the  loop  of 
wire  is  passed  over  it,  and  removal  effected  by  constriction.  When 
there  is  a  broad  base,  the  whole  mass  is  seized  with  the  polypus-for- 
ceps, and  the  snare  is  then  passed  over  it  and  tightened  until  it 
comes  away. 

There  is  one  accident  that  very  often  occurs  in  this  operation, 
and  that  is  breaking  of  the  wire.  This  takes  place,  usually,  just 
when  the  tumor  is  almost  cut  off,  and  it  annoys  and  hinders  the 
operator,  but  does  not  spoil  the  operation,  as  a  new  piece  of  wire 
can  be  used,  and  the  operation  completed.  This  accident  can  often 
be  avoided  by  taking  time.  The  base  or  pedicle  of  most  of  these 
growths  wiU  give  way  under  long-continued  pressure,  but  the  wire 
will  break  if  there  is  too  much  hurry. 

In  order  to  operate  high  up  in  the  urethra,  it  is  sometimes 
necessary  to  dilate  its  lower  portion.  A  convenient  way  to  do  this 
is  the  following :  Take  a  piece  of  fine  rubber  tubing  and  draw  it 
over  the  blades  of  the  Folsom  speculum,  and  then  introduce  the  in- 
strument into  the  urethra.  Open  the  blades,  and  let  it  distend  the 
urethra  as  far  as  it  can.  To  produce  the  extra  dilatation,  take  a 
series  of  graduated  sounds  or  dilators — wood  or  hard  rubber  will 
answer — and  force  one  of  these  in  between  the  blades  of  the  specu- 
lum ;  remove  that  one,  and  use  a  size  larger,  and  so  on  until  the 
requisite  amount  of  dilatation  is  obtained.  The  blades  of  the  specu- 
lum and  the  rubber  tubing  protect  the  mucous  membrane  of  the 
urethra  from  injury  while  passing  in  the  dilator.  The  danger  of  in- 
continence of  urine,  which  is  liable  to  follow  from  forcible  dilata- 


ORGANIC  DISEASES   OF  THE  FEETHRA.  847 

tion,  can  be  avoided  by  distending  the  lower  portion  of  the  urethra 

only. 

To  obtain  sufficient  light  for  operating  high  up  in  the  urethra, 
it  is  necessary  to  have  clear  sunlight ;  or,  if  that  is  not  obtainable, 
gaslight  should  be  used  ;  and,  in  either  case,  the  concave  head-mir- 
ror should  be  employed. 

Of  late  years  the  galvano-cautery  has  been  very  extensively 
used  in  surgery  generally,  and  has  been  recommended  for  the  re- 
moval of  urethral  tumors.  As  a  means  of  removing  large  and  vas- 
cular growths  from  the  meatus,  it  has  high  claims,  but  for  general 
use  it  will  be  found  objectionable.  In  removing  tumors  from  the  in- 
terior of  the  urethra  with  this  cautery,  it  is  impossible  to  avoid  cau- 
terizing portions  of  the  normal  membrane  unless  extraordinary  skill 
is  employed.  This  unfortunate  liability,  and  the  difficulty  in  keep- 
ing the  instrument  in  good  working  order,  stand  in  the  way  of  this 
means  of  operating  ever  becoming  popular  in  this  dejjartment  of 
surgery. 

Caustics  have  been  more  extensively  used  than  any  other  means 
of  removing  urethral  neoplasms,  and  1  know  of  no  better  w^ay  of 
destroying  small  growths.  Of  all  the  agents  used,  I  prefer  pure 
nitric  acid,  which  I  use  as  follows :  Exposing  the  tumor  with  the 
speculum,  represented  by  Fig.  245,  I  w^ap  a  little  cotton  around  a 
probe,  and  dip  it  into  the  acid,  and  apply  it  to  the  part  to  be  de- 
stroyed, taking  care  not  to  touch  any  of  the  normal  tissues.  The 
speculum  recommended  has  the  advantage  of  protecting  one  side  of 
the  canal,  and,  by  exercising  care  in  handling  the  acid,  accidents 
may  be  avoided. 

I  come  now  to  the  last  method  of  removing  these  tumors  which 
I  shall  mention,  viz.,  electrolysis.  This  means  of  treating  abnormal 
growths  has  been  employed  so  much  lately  that  I  need  not  dwell 
upon  the  method  of  its  use,  but  simply  state  that  those  tumors  that 
recur,  and  those  that  are  suspected  to  be  malignant,  and  those  also 
that  are  so  high  up  in  the  urethra  as  to  be  difficult  to  remove,  should 
be  treated  by  electrolysis.  Two  long,  slender  needles  should  be  in- 
sulated by  coating  them  with  collodion,  except  at  the  points.  These 
are  attached  to  the  electrodes  of  a  galvanic  battery,  and  their  points 
introduced  into  the  base  of  the  tumor,  and  the  current  passed  through 
until  the  whole  of  the  abnormal  tissue  is  decomposed.  I  prefer  to 
use  a  current  sufficiently  strong  to  char  the  tumor,  and  thereby  com- 
pletely destroy  it. 

There  is  one  rule  which  should  be  kept  in  mind  in  treating 
tumors  of  the  urethra,  and  that  is,  to  be  sure  to  remove  all  the  ab- 


848  DISEASES   OF  WOMEN". 

normal  tissue.  Whatever  method  is  employed,  no  portion  of  that 
which  ought  to  be  removed  should  be  left.  I  am  confident  that 
much  of  the  trouble  experienced  by  the  repeated  return  of  these 
growths  might  be  avoided  by  a  careful  observance  of  this  rule. 

Urethral  catarrh  or  infiammation,  which  frequently  accompanies 
abnormal  growths,  usually  subsides  after  their  removal.  In  some 
cases  it  persists,  and  then  it  should  be  treated  according  to  the 
methods  already  given. 


CHAPTER  XLYII. 

OEGANIC   DISEASES    OF   THE   IJEETHEA    (CONTINUED). 
DILATATION,  DISLOCATION,  AND  PROLAPSUS. 

5.  Dilatation  of  the  Urethra. — Changes  in  the  caliber  of  the  female 
urethra  occur  in  two  forms,  dilatation  and  contraction ;  but  neither 
of  these  is  very  often  met  with  in  practice.  Of  the  two,  dilatation 
is  the  more  common.  The  increase  in  the  size  of  the  nrethra  may 
involve  the  whole  canal,  or  be  limited  to  a  portion  of  it.  I  will  first 
speak  of  dilatation  of  the  whole  urethra,  and  then,  dividing  the  canal 
into  thirds,  consider  the  affection  of  each  portion. 

Dilatation  of  the  Whole  Urethra. — It  will  be  understood  that  dila- 
tation to  such  an  extent  as  to  have  the  canal  open  and  its  walls  sepa- 
rated is  an  unknown  condition.  The  true  state  of  things  would  be 
more  correctly  expressed  by  calling  it  an  abnornia'l  dilatability.  The 
tissues  of  the  walls  of  the  urethra  are  in  such  a  relaxed  condition  as 
to  admit  of  extraordinary  distention  without  injury.  Dilatation  of 
the  whole  ui'ethra  is  not  so  common  as  dilatation  of  a  portion.  Even 
when  the  whole  canal  is  larger  than  it  should  be,  it  will  generally  be 
found  that  it  is  not  uniformly  so.  Some  portions  of  it  are  more 
distended  than  others.  The  extent  to  which  this  dilatation  may 
occur  is  very  great.  A  number  of  cases  are  recorded,  especially  in 
the  German  literature  of  the  subject,  where  copulation  took  place 
for  years  in  the  urethi-a  instead  of  the  vagina.  In  these  cases  the 
dilatation  was  extreme. 

In  this  affection  the  urethral  walls  and  the  urethro-vaginal  sep- 
tum are  usually  relaxed  and  flabby.  After  a  considerable  time  they 
may  become  indurated  by  infiltration,  or  by  hyperplasia  of  the  con- 
nective tissue.  The  mucous  membrane  is  usually  soft  and  loosely 
adherent  to  the  subjacent  tissues.  Beneath  the  membrane  will  some- 
times be  found  masses  of  enlarged  veins,  which  give  a  dark-bluish 
appearance  to  the  parts.  If  the  meatus  be  distended  like  the  rest  of 
55 


850  DISEASES   OF  WOMEN. 

the  urethra,  the  mucous  membrane,  with  the  large  veins  beneath  it, 
may  protmde  and  form  tumors,  which  will  have  quite  the  appear- 
ance of  rectal  hsemorrhoids.  This  is  especially  so  when  the  veins 
are  large  and  numerous,  and  the  mucous  membrane  thin,  so  that 
the  color  of  the  veins  can  be  seen  through  it.  On  the  other  hand, 
if  the  meatus  remains  normal  in  size  nothing  will  be  seen  by  the 
examiner  until  the  catheter  or  sound  is  passed  into  the  urethra, 
when  the  distended  or  distensible  condition  of  the  canal  will  be  de- 
tected. The  dilatation  can  easily  be  made  out,  even  when  the  meatus 
is  normal  in  size,  by  observing  that  the  sound  can  be  moved  about 
in  the  urethra,  conveying  the  same  impression  to  the  hand  as  when 
it  passes  into  the  bladder.  By  making  a  digital  examination  of 
the  vagina  the  enlarged  urethra  can  be  felt,  and  is  usually  elastic 
and  compressible.  Through  Sims's  speculum  the  abnormal  fullness 
or  bulging  of  the  anterior  vaginal  wall  can  be  plainly  seen  and  dis- 
tinguished from  displacement  of  the  urethra.  The  points  of  differ- 
ence between  dilatation  and  displacement  will  be  brought  out  more 
in  detail  further  on. 

When  the  dilatation  has  existed  for  any  length  of  time,  the 
mucous  membrane  is  usually  hypersemic  and  sometimes  catarrhal, 
secreting  a  muco-purulent  material,  which  may  be  seen  escaping  from 
the  meatus,  or  lodged  in  the  folds  of  the  membrane,  where  it  can  be 
observed  through  the  endoscope.  When  the  mucous  membrane  is 
prolapsed  and  forms  a  tumor  outside  of  the  meatus,  it  soon  becomes 
lissured  and  ulcerated,  and  consequently  very  tender  and  painful. 
This  condition  is  produced  by  the  retarded  circulation,  chafing,  and 
the  irritation  from  exposure  to  the  air,  and  the  urine  passing  over  it. 

Dilatation  of  the  Anterior  or  Lower  Third. — This  is  the  rarest  of 
all  the  forms  of  urethral  dilatation,  and  occurs  usually  as  a  conse- 
quence of  some  enlargement  or  swelling  of  the  mucous  membrane, 
neoplasm  of  the  urethra,  or  mechanical  dilatation.  The  dilatation 
may  include  the  meatus  or  it  may  not.  In  rare  cases  it  does  not  at 
first,  but  later  in  the  course  of  the  trouble  the  enlarged  mucous 
membrane  slowly,  sometimes  rapidly,  dilates  the  orifice.  The  gen- 
eral appearances  of  the  parts  are  the  same  as  those  of  which  I  have 
spoken  under  the  head  of  dilatation  of  the  whole  urethra.  When 
the  dilatation  is  due  to  any  abnormal  growth  in  the  urethra,  the 
conditions  presented  will  be  the  same  as  those  already  described 
under  the  head  of  urethral  neoplasms. 

I  have  seen  but  one  case  where  the  lower  end  of  the  urethra 
was  dilated  without  any  recognizable  cause  for  it.  This  was  a  sin- 
gle lady,  thirty-five  years  of  age,  a  school-teacher.     She  had  dis- 


ORGANIC   DISEASES   OF   THE   URETHRA.  851 

placement  of  the  uterus  and  catarrh  of  the  cervical  canal,  for  which 
she  consulted  me.  She  had  no  trouble  with  her  urinary  organs. 
While  examining  the  uterus  I  noticed  that  the  meatus  urinarius  was 
peculiarly  formed.  In  place  of  the  concentric  corrugations  of  the 
mucous  membrane  which  form  the  closed  meatus,  the  orifice  was 
funnel-shaped,  and  lay  open  when  the  labia  minora  were  separated. 
About  half  an  inch  of  the  lower  end  of  the  urethra  admitted  a 
JSTo.  21  (English)  sound.  The  remainder  of  the  m-ethra  was  normal, 
and  there  were  no  signs  of  disease  about  the  mucous  membrane  of 
the  dilated  portion.  I  could  obtain  no  history  which  pointed  to  the 
origin  of  the  dilatation,  and  it  caused  no  discomfort  to  the  patient. 

Dilatation  of  the  Posterior  or  Upper  Third. — This  forai  of  dilata- 
tion usually  occurs  in  connection  with  other  pathological  conditions, 
such  as  prolapsus  of  the  bladder  and  urethra.  On  this  account  I 
will  defer  what  is  to  be  said  on  this  subject  until  I  come  to  disloca- 
tions of  the  urethra. 

Dilatation  of  the  Middle  Third  of  the  TTrethra. — Dilatation  of  this 
part  of  the  urethra  is  more  common  than  either  of  those  I  have 
described.  I  do  not  desire  to  be  understood  as  saying,  that  it  is  con- 
fined to  exactly  the  middle  third  of  the  urethra,  or  that  the  other 
dilatations  are  confined  to  thirds  only.  It  is  about  a  third,  and  I 
use  the  division  to  fix  the  idea  clearly  in  the  mind  and  for  conven- 
ience of  description. 

In  this  form  of  dilatation  the  anterior  wall  of  the  urethra  main- 
tains its  normal  position,  but  the  central  portion  of  the  canal  being 
distended  settles  down,  so  that  in  time  the  urethra,  in  place  of  be- 
ing a  straight  or  slightly  curved  canal,  becomes  triangular,  the 
upper  wall  being  the  base,  and  the  central  portion  of  the  posterior 
wall  (that  is  midway  between  the  neck  of  the  bladder  and  the 
meatus)  the  apex.  A  cavity  is  thus  formed  in  the  central  portion 
of  the  urethra.  Fig.  246  will  convey  the  idea  of  the  anatomical 
appearances  of  this  affection. 

This  form  of  dilatation  has  been  called  sacculated  urethra  and 
urethrocele.  A  valuable  article  on  this  subject  will  be  found  in  the 
"American  Journal  of  Obstetrics"  for  February,  1871,  by  Nathan 
Bozeman,  M.  D.  Some  of  the  cases  related  there  by  him  are,  in 
my  opinion,  not  simply  urethral  dilatation  alone,  but  dilatation  and 
dislocation  combined.  However,  his  description  of  this  form  of 
trouble  is  the  best  that  I  have  ever  seen,  and  I  prefer  to  give  it  in 
his  own  words.     It  is  as  follows : 

"  In  the  study  of  urethrocele,  the  anatomical  points  to  be  consid- 
ered are  the  triangular  ligament  and  its  relations  with  the  urethra, 


852 


DISEASES   OF   WOMEN. 


the  muscular  structure  of  the  urethra,  and  the  different  relations  of 
the  urethra  to  the  vagina  in  the  upper  and  lower  parts  of  its  course. 


Fig.  246. — Dilatation  of  middle  third  of  the  urethra  (urethrocele). 

"  These  anatomical  peculiarities  exert  a  marked  influence  on  the 
etiology  of  the  lesions  in  question,  and  supply  the  first  links  in  the 
long  chain  of  morbid  results  indicated  by  the  histories  of  the  cases 
above  cited,  and  others  known  sometimes  to  follow. 

"  In  the  male,  stricture,  although  not  the  first  morbid  alteration, 
denotes  the  first  serious  interruption  of  the  stream  of  urine,  and 
superinduces  morbid  changes  in  the  urethra  above  the  prostate 
gland,  in  the  bladder,  the  ureters,  and  the  kidneys. 

"  In  the  female,  rare  as  it  is  to  meet  with  organic  stricture  of  the 
same  kind  as  in  the  male,  the  caliber  of  the  canal  is  quite  as  often, 
if  not  oftener,  compromised,  and  with  due  allowance  for  the  ana- 
tomical differences  of  sex,  the  pathologic  sequences  observe  the 
same  order. 

"  The  starting-point  of  urethral  and  vesical  lesions  in  the  female 
is  to  be  sought  in  the  lower  half  of  the  urethra,  closely  related  in 
front  with  the  triangular  ligament,  and  blending  behind  with  the 
spongy  erectile  tissue  of  the  vagina. 

"  The  caliber  of  the  urethra  may  be  transiently  narrowed  by 


OKGANIO  DISEASES   OF  THE    URETHRA.  853 

congestion  of  its  mucous  lining,  or  permanently  narrowed  by  infil- 
tration of  coagulable  lymph  into  the  underlying  cellulo-elastic  tis- 
sue, which  constitutes  properly  the  so-called  organic  stricture,  as  in 
the  male,  and  which,  however  seldom  met  with,  is  liable  to  the  same 
sequences. 

"  Infiltration  into  the  spongy  erectile  tissue  outside  the  urethra, 
by  plastic  lymph,  is,  I  believe,  by  far  the  most  common  beginning 
of  the  morbid  process,  whatever  be  the  cause  that  produces  it.  This 
interrupts  the  stream  of  urine,  either  by  encroaching  on  the  caliber 
of  the  urethra,  or  by  deflecting  it  beneath  the  triangular  ligament, 
both  cases  being  attended  with  more  or  less  dilatation  above. 

"  The  next  step  in  sequence  is  increased  functional  activity  of  the 
urethral  muscular  coat  in  overcoming  the  obstmction  to  the  flow  of 
urine.  The  result  upon  its  structure  is  hypertrophy,  and  this  will 
be  of  the  eccentric  type,  thickening  the  urethral  walls  while  enlarg- 
ing the  cahber.  Hence  the  ease  with  which  large  catheters  of  a 
proper  curve  pass  at  all  stages  of  the  disease.  False  and  true  hyper- 
trophy here  coexist.  The  true  hypertrophy  increases  jpari  passu 
with  the  muscular  contraction,  and  is  followed  by  still  greater  distor- 
tion of  the  canal,  at  an  angle  more  and  more  acute,  as  it  turns  the 
triangular  ligament,  and  with  corresponding  coarctation  of  its  walls 
at  that  point.  This  mechanical  impediment  below  coincides  with 
the  increased  weight  and  volume  of  the  stream  of  urine  above,  to 
put  the  walls  of  the  urethra  on  the  stretch  in  the  upper  part  of  its 
course. 

"  Thus  is  gradually  formed  the  urinous  tumor,  which  drags  down 
in  front  the  adjacent  vaginal  wall,  appearing  as  a  prolapsus  between 
the  nymphge,  and  filling  up  ths  ostium  vaginae. 

"  The  looser  attachment  of  the  urethra  to  the  vagina  in  the  upper 
part  of  its  course  facilitates  this  result.  Such  is  the  condition  of  the 
parts  to  which  I  apply  the  term  urethrocele.  Often  confounded 
with  cystocele,  it  is  really  distinct. 

"  The  arrest  and  retention  of  but  a  few  drops  of  urine  at  first 
goes  on  until  this  may  amount  to  a  teaspoonful  or  more.  It  is  then 
decomposed  in  this  pocket,  becomes  alkaline,  and  by  its  irritation 
provokes  congestion  of  the  urethral  mucous  membrane." 

In  the  earlier  stages  of  this  affection  the  urethra  in  front  and 
behind  the  pouch  is  really  or  apparently  contracted ;  but  as  the 
disease  progresses  the  upper  part  of  the  canal  and  the  neck  of  the 
bladder  become  dislocated  downward,  and  finally  the  upper  portion 
of  the  urethra  becomes  also  dilated  to  some  extent. 

There  is  in  this,  as  in  the  other  forms  of  urethral  dilatation,  fre- 


854  DISEASES   OF   WOMEN". 

qnent  urination,  usually  more  marked  ;  but  unlike  the  others,  there 
is  difficulty  in  passing  water.  This  frequency  of  urination,  and 
the  straining  efforts  necessary,  affect  the  bladder,  producing  irri- 
tation, and,  in  time,  hypertrophy  of  its  walls.  Cystitis  also  follows 
in  the  order  of  morbid  developments ;  but  whether  that  comes 
from  the  frequent  and  difficult  urination,  or  from  extension  of  the 
inflammation  from  the  urethra  to  the  bladder,  is  a  question.  One 
thing  we  know,  and  that  is,  that  if  this  form  of  uretliral  dilatation 
goes  on  without  treatment,  cystitis  will  sooner  or  later  appear. 

Symptomatology. — The  symj)toms  vary  according  to  the  extent  of 
the  dilatation,  the  portion  of  the  urethra  involved,  and  the  condition 
of  the  mucous  membrane.  When  the  whole  urethra  is  dilated,  the 
only  symptom  present  may  be  frequent  urination.  When  there  is 
inflammation  or  prolapsus  of  the  mucous  membrane,  then  pain  will 
be  caused  by  micturition,  and  the  desire  to  micturate  will  be  more 
urgent  and  frequent.  The  patient  may  also  be  annoyed  by  a  slight 
loss  of  control  of  the  bladder,  under  the  pressure  of  lifting  heavy 
weights  or  coughing. 

Dilatatation  of  the  lower  third  of  the  urethra  does  not  cause  any 
derangement  of  function,  unless  accompanied  with  inflammation  or 
ulceration ;  then  there  will  be  frequent  urination  possibly,  painful 
urination  certainly.  The  symptoms  in  this  form  of  dilatation  are 
less  marked  than  in  the  other  varieties. 

When  the  trouble  is  located  in  the  upper  third  of  the  urethra, 
the  symptoms  are  sometimes  very  distressing.  In  addition  to  the 
frequent — it  may  be  constant — desire  to  pass  water,  the  patient  is 
tormented  with  partial  incontinence.  Coughing,  laughing,  sneezing, 
stooping  to  lift  anything,  a  jar  on  stepping  from  the  curbstone  in 
crossing  the  street,  causes  an  escape  of  urine.  This  distresses  the 
patient  very  greatly.  She  is  not  troubled  so  long  as  she  keeps  quiet, 
or  at  least  she  suffers  only  from  frequent  urination  ;  but  as  soon  as 
she  undertakes  the  usual  duties  of  exercise  or  enjoyment,  then  this 
partial  incontinence  makes  her  miserable.  From  the  constant  wetting 
of  the  external  parts  they  become  inflamed,  unless  very  great  care  is 
taken  to  keep  them  dry  and  clean.  In  some  of  these  cases  the  morti- 
fication is  sometimes  more  distressing  than  the  physical  suffering. 

The  symptoms  occurring  in  dilatation  of  the  middle  portion  of 
the  urethra  (urethrocele)  are  the  same  as  those  already  given,  with 
the  addition  of  a  slight  mechanical  obstruction,  which  causes  difficult 
urination.  That  is,  more  voluntary  effort  is  necessary  on  the  pari  of 
the  patient  to  empty  the  bladder.  The  forcing,  straining  efforts 
made  by  some  of  these  patients  while  urinating  are  even  greater 


OEGANIC  DISEASES   OF  THE   URETHRA.  855 

than  the  mechanical  obstruction  appears  to  account  for.  This  may 
be  due  to  the  accumulation  of  urine  in  the  urethra,  which  excites 
extra  reflex  action  in  the  bladder  and  urethra  out  of  proportion  to 
the  obstruction.  This  is  the  only  way  that  I  can  account  for  the 
difficult  urination  and  muscular  hypertrophy  found  in  these  cases  in 
which  there  is  no  obstruction  from  stricture. 

The  constitutional  symptoms  arising  from  these  urethral  troubles 
are  the  same  as  those  produced  by  urethritis,  and  are  not  peculiar  to 
this  class  of  affections.  In  fact  it  will  be  observed  that  the  symptoms 
here  given  may  all  be  produced  by  other  pathological  conditions,  and 
consequently  can  not  alone  guide  to  correct  diagnoses.  The  clinical 
history  in  such  cases  leads  us  to  suspect  the  nature  of  the  disease, 
but  the  true  character  of  the  trouble  can  only  be  discovered  by 
jphysical  exploration. 

Diagnosis. — In  dilatation  of  the  whole  urethra,  a  digital  exam- 
ination will  detect  the  increased  space  occupied  by  the  urethra.  The 
canal  encroaches  upon  the  anterior  vaginal  wall,  and  feels  like  a 
ridge  extending  from  the  meatus  to  the  neck  of  the  bladder.  This 
elevation  or  thickening  of  the  urethra  is  elastic  and  compressible  in 
recent  cases  ;  in  those  of  long  standing  where  there  is  hypertrophy, 
the  tissues  are  firm  to  the  touch,  but  still  the  canal  is  compressible. 
The  extent  of  the  dilatation  can  be  measured  by  the  size  of  the 
sound  that  can  be  easily  passed.  If  even  the  ordinary  female  catheter 
is  at  hand  an  idea  of  the  size  of  the  canal  may  be  obtained.  By 
introducing  that  instrument  and  pressing  it  first  against  the  anterior 
wall  and  then  upon  the  posterior,  the  distance  between  the  two  can 
be  approximately  made  out.  While  the  catheter  or  sound  is  in  the 
urethra  the  finger  should  be  introduced  into  the  vagina  and  the 
thickness  of  the  urethral  wall  ascertained.  This  will  give  a  good 
idea  of  the  increase  of  tissue  from  inflammatory  products  or  hyper- 
trophy. 

When  the  meatus  is  dilated  and  the  mucous  membrane  and  en- 
larged vessels  are  prolapsed,  care  must  be  exercised  to  distinguish 
that  condition  from  urethral  neoplasm.  This  can  be  done  by  ob- 
serving that  in  prolapsus  the  opening  is  situated  either  at  the  upper 
side  or  in  the  center  of  the  protruding  mass,  whereas  in  abnormal 
growths  of  the  urethra  the  meatus  surrounds  the  tumor  or  its 
pedicle.  More  than  that,  by  making  pressure  on  the  distended 
vessels  the  size  of  the  prolapsed  membrane  can  be  reduced,  and  the 
membrane  can  be  pushed  up  into  the  canal.  This  can  not  usually 
be  done  with  tumors. 

Dilatation  of  the  lower  third  of  the  urethra  is  easily  diagnosti- 


856  DISEASES   OF   WOMEN". 

cated.  A  large  sound  will  pass  in  as  far  as  the  dilatation  extends, 
and  will  be  arrested  when  it  conies  to  that  portion  of  the  canal  which 
has  a  normal  caliber. 

Great  difficulty  will  be  encountered  in  the  diagnosis  of  dilatation 
of  the  upper  third  of  the  urethra,  but  by  attention  to  the  following 
points  success  will  usually  follow.  By  using  the  sound  it  will  be 
observed  that  while  the  lower  portion  of  the  canal  hugs  the  instru- 
ment firmly,  the  point  of  it  can  be  moved  freely  in  the  upper  part 
of  the  passage.  The  same  impression  is  conveyed  through  the  in- 
strument as  that  which  is  experienced  when  the  sound  enters  the 
bladder;  only  in  dilatation  of  the  upper  portion  of  the  urethra,  the 
motion  of  the  point  of  the  sound  is,  of  course,  more  limited.  Again, 
by  introducing  a  curved  sound,  and  with  it  holding  the  anterior  wall 
of  the  urethra  well  up  under  the  arch  of  the  pubes,  and  then  carrying 
the  finger  of  the  other  hand  along  the  anterior  vaginal  wall,  the 
posterior  wall  of  the  urethra  will  be  found  to  hug  the  sound  until 
the  dilated  portion  is  reached  ;  this  will  be  felt  to  lie  away  from  the 
instrument.  By  pushing  up  the  vaginal  and  urethral  walls  at  the 
point  of  dilatation  until  they  touch  the  sound,  and  then  by  remov- 
ing the  pressure  and  allowing  the  parts  to  recede  from  the  sound, 
the  relaxation  can  be  easily  detected. 

In  some  well-marked  cases  of  dilatation  complicated  with  pro- 
lapsus of  the  upper  portion  of  the  urethra,  tlie  diagnosis  can  be 
clearly  made,  by  slowly  introducing  the  catheter  until  the  urine  be- 
gins to  flow,  and  then  marking  the  catheter  at  the  meatus  urinarius 
and  withdrawing  it.  The  distance  from  the  mark  made  to  the 
upper  edge  of  the  eye  of  the  catheter  indicates  the  length  of  the 
normal  portion  of  the  urethra.  If  that  is  subtracted  from  the 
normal  length  of  the  urethra,  the  remainder  will  indicate  the  length 
of  the  dilated  portion. 

Dilatation  of  the  middle  third  of  the  urethra — urethrocele — is 
most  likely  to  be  confounded  with  thickening  of  the  urethro-vaginal 
septum.  The  diagnosis  is  made  by  observing  that  the  enlargement 
due  to  dilatation  corresponds  to  the  central  portion  of  the  urethra, 
and  that  it  yields  to  pressure  more  or  less.  Also,  by  passing  a 
curved  sound  with  the  point  upward,  the  anterior  wall  of  the  urethra 
will  be  found  to  occupy  its  normal  position.  Withdrawing  the  sound 
and  again  introducing  it  with  the  point  downward  it  will  pass  in- 
ward and  then  down  into  the  pocket  found  at  the  point  of  dilatation, 
where  it  can  be  felt  through  the  vaginal  wall. 

In  all  cases,  except  one,  that  have  come  under  my  observation, 
the  diagnosis  has  been  easily  made  by  this  method  of  examination. 


ORGANIC   DISEASES   OF   THE   URETHRA.  85Y 

The  exception  referred  to  was  a  case  of  periurethral  inflammation, 
in  which  an  abscess  formed  in  the  urethro-vaginal  septum  and  dis- 
charged into  the  urethra.  A  fistulous  opening  from  the  floor  of  the 
urethra  into  the  sac  of  the  abscess  remained.  The  urethra  occupied 
its  normal  position,  and  admitted  the  sound  easil}^;  and  bj  intro- 
ducing it  with  the  point  downward  it  passed  into  the  sac  of  the 
abscess,  thus  giving  the  physical  signs  of  urethrocele ;  but  the  small 
size  of  the  opening  in  the  floor  of  the  urethra,  the  marked  infiltra- 
tion and  induration  of  the  tissues,  and  the  history  of  the  case,  led 
to  a  diagnosis  of  its  true  character. 

Prognosis. — There  is  no  natural  tendency  to  recovery  in  these 
affections.  If  left  alone  they  generally  get  worse ;  recovery  under 
treatment  is  modified  by  the  location  of  the  dilatation  and  the  dura- 
tion of  the  trouble.  The  conditions  upon  which  an  unfavorable 
prognosis  is  to  be  based  are  bladder  complications,  inflammation  or 
ulceration  near  the  neck  of  tlie  bladder,  great  varicosity  of  the  veins, 
and  fatty  degeneration  of  the  muscular  tissue.  In  the  absence  of 
all  these  complications  a  complete  cure  can  be  obtained.  In  all 
cases  great  relief  can  be  secm-ed  by  treatment,  and  the  patient 
guarded  from  getting  worse. 

Causation. — The  hypersemia  of  the  urethra  which  occurs  in 
pregnancy,  and  which  tends  to  produce  overdistention  of  the  veins, 
favors  dilatation  of  the  whole  urethra.  It  is  not  uncommon  to  find 
an  apparent  increase  of  tissue  in  the  walls  of  the  urethra  during 
utero-gestation,  and  the  dilatability  of  the  canal  is  often  increased 
also.  This  condition  of  the  parts  disappears  during  the  involution 
which  takes  place  after  delivery ;  but  when  from  any  cause  the 
process  of  involution  is  interrupted,  the  enlarged  vessels  and  relaxed 
condition  of  the  urethral  walls  remain  and  sometimes  increase. 
When  to  this  state  of  the  parts  a  catarrh  of  the  mucous  membrane 
is  added,  the  enlargement  of  the  membrane  by  swelling  still  further 
increases  the  caliber  of  the  canal. 

The  dilatation  caused  by  passing  calculi  may  remain  permanently, 
and  the  same  may  be  said  of  the  use  of  large  sounds.  Neoplasms 
obstructing  the  meatus,  or  stricture  at  that  point,  may  so  obstruct 
the  escape  of  the  urine  as  to  cause  dilatation  at  all  points  above.  This 
is  no  doubt  one  of  the  most  important  and  frequent  causes  of  dilata- 
tion. Indeed,  the  recognition  of  this  fact  has  led  to  the  suggestion 
of  treating  stricture  of  the  upper  portions  of  the  urethra  by  com- 
pressing the  meatus,  and  then  forcing  the  urine  into  the  urethra  and 
retaining  it  there. 

I  have  already  stated  that  dilatation  of  the  lower  third  of  the  ure- 


858  DISEASES   OF   WOMEN. 

thra  is  rare,  and  is  usually  due  to  inflammation  of  the  mucous  mem- 
brane at  that  point  or  to  abnormal  growths,  the  distention  remaining 
after  the  causes  that  produced  it  have  been  removed.  This  and 
mechanical  dilatation  from  any  cause  cover  the  etiology  of  this  form 
of  the  dilatation.  Baker  Brown  says  that  the  meatus  is  always 
dilated  when  there  is  stone  in  the  bladder. 

Regarding  dilatation  of  the  upper  third  of  the  urethra,  I  am  in- 
clined to  believe  that  it  occurs  in  consequence  of  a  partial  prolapsus 
of  the  bladder  and  the  upper  end  of  the  urethra.  The  displacement 
of  these  parts  implies  a  relaxation  of  the  tissues,  caused  originally, 
it  may  be,  by  injuries  during  confinement,  and  the  prolapsus  permits 
an  unusual  pressure  of  the  urine  upon  the  upper  end  of  the  urethra, 
and  dilatation  is  the  result.  On  the  other  hand,  the  prolapsus  and 
the  accompanying  relaxation  of  the  urethral  walls  may  be  sufficient 
to  cause  the  dilatation,  and  the  whole  trouble  can  invariably  be  traced 
to  child-bearing  or  anteversion  of  the  uterus.  The  fact  that  the 
upper  part  of  the  urethra  is  torn  from  its  attachment  to  the  subpubic 
ligament,  and  thereby  deprived  of  its  normal  supports,  would  incline 
it  to  dilate,  and  I  presume  that  this  is  oftentimes  the  cause  of  the 
dilatation. 

One  cause  of  dilatation  of  the  middle  third  of  the  urethra  (ure- 
throcele) has  been  sufficiently  dwelt  upon  in  Bozeman's  description 
of  the  pathology  of  that  affection — that  is,  narrowing  of  the  lower 
end  of  the  urethra.  This  does  not  explain  the  etiology  of  all  cases, 
however,  for  1  have  seen  this  form  of  dilatation  where  there  was  no 
stricture  or  hypertrophy  of  the  lower  end  of  the  urethra.  In  such 
cases  I  have  traced  th^  cause  to  childbirth,  during  which  the  pos- 
terior wall  of  the  urethra  had  been  pushed  downward  and  contused, 
while  the  upper  remained  in  its  normal  position.  The  relaxation 
caused  by  this  overstretching  of  the  urethral  wall  formed  a  small 
pocket  in  the  central  portion,  which  gradually  dilated  more  and  more 
by  the  pressure  of  the  urine  until  the  urethrocele  was  fully  devel- 
oped. This  explanation  of  the  cause  may  be  rather  hypothetical, 
but,  so  far  as  my  observations  go,  it  agrees  with  the  facts  found  in 
those  cases  which  can  not  be  accounted  for  by  Bozeman's  views  on 
the  pathology  of  this  affection. 

Treatment. — In  the  management  of  all  forms  of  urethral  dila- 
tation, any  inflammation  of  the  mucous  membrane  that  may  exist 
should  be  relieved  by  employing  the  usual  methods  of  treatment  of 
urethritis.  When  there  is  a  relaxed  and  prolapsed  condition  of  the 
mucous  membrane,  astringents  should  be  used  to  overcome  it.  Tan- 
nic acid  will  answer  well.     When  these  fail,  the  redundant  mem- 


ORGANIC   DISEASES   OF   THE   URETHRA.  859 

brane  should  be  retrenched,  either  by  touching  it  with  the  thermo- 
cautery or  excising  a  portion  with  the  scissors.  In  employing  the 
cautery  for  this  purpose,  the  long-pointed  tip  of  the  instrument 
which  is  used  for  cauterizing  haemorrhoids  by  puncture  should  be 
chosen,  and,  having  protected  one  side  of  the  urethra  with  the  specu- 
lum, a  narrow  strip  of  the  membrane  parallel  to  the  axis  of  the 
canal  shall  be  cauterized.  Two  or  more  of  these  cauterizations  may 
be  made  at  points  equidistant  on  the  circumference  of  the  urethra. 
Operating  in  this  way  leaves  pieces  of  normal  meml)rane  between 
the  portions  cauterized,  which  prevents  stricture  from  occurring 
after  healing — a  misfortune  which  is  sure  to  follow  if  the  mucous 
membrane  is  destroyed  by  cauterization  all  round. 

In  excising  the  prolapsed  portion,  I  prefer  to  remove  one  or  more 
Y-shaped  portions  on  opposite  sides,  and  bring  the  edges  together 
by  sutures.  This  is  preferable  to  clipping  off  the  whole  of  the  pro- 
truding mass,  because  the  cicatrices  left  are  less  likely  to  give  after- 
trouble  by  contraction. 

When  the  dilatation  is  caused  by  varicose  veins,  it  may  be  well 
to  follow  the  example  of  Gustavo  Simon.  He  exposed  the  vessels 
by  cutting  through  the  vaginal  wall,  ligated  the  largest,  and  arrested 
the  haemorrhage  from  the  smaller  ones  by  applying  liquor  ferri  per- 
chloridi.  He  repeated  this  operation  several  times  on  the  same  pa- 
tient, who  experienced  little  or  no  inconvenience  from  the  proceed- 
ings, and  made  a  good  recovery. 

Dilatation  of  the  lower  third  of  the  urethra  is  usually  secondary 
to  some  other  trouble,  as  I  have  already  stated,  and  all  that  the  physi- 
cian will  usually  be  called  upon  to  do  for  such  cases  is  to  remove  the 
cause  and  treat  any  inflammation  that  may  exist.  The  dilatation  will 
then  disappear,  and,  if  it  does  not,  but  little,  if  any,  trouble  will  result. 

The  treatment  of  dilatation  of  the  upper  third  consists  simply  in 
supporting  the  parts.  This  can  be  effectually  done  by  using  the 
pessary  already  recommended  for  the  relief  of  prolapsus  of  the  blad- 
der. It  will  be  necessary  to  have  the  instrument  so  formed  as  to 
bring  the  pressure  where  it  is  required.  This  can  easily  be  done  by 
placing  the  pessary  in  position,  and  observing  what  change  of  form, 
if  any,  is  necessary,  and  then  directing  the  instrument-maker  to  make 
the  alteration.  If  the  parts  are  well  supported  in  this  way,  recovery 
will  follow,  unless  atrophy  of  the  muscular  wall  has  previously  taken 
place.  Even  then  the  patient  can  be  kept  comfortable  by  wearing 
the  pessary.  If  there  is  urethritis  present,  it  may  be  necessary  to 
relieve  that  before  using  the  pessary ;  otherwise,  the  pressure  of  the 
instrument  may  cause  pain,  and  aggravate  the  inflammation. 


860  DISEASES   OF  WOMEN. - 

This  brings  me  to  the  only  remaining  form  of  this  affection  to  be 
mentioned — dilatation  of  the  middle  third,  or  urethrocele.  Dr.  Boze- 
man  has  proposed  making  an  opening  into  the  most  dependent  part 
of  the  urethra  through  the  vaginal  wall,  and  maintaining  it  until  all 
inflammation  has  been  relieved,  and  then  closing  the  opening  by  the 
usual  plastic  operation.  By  this  means  the  urethra  is  perfectly 
drained  of  urine  and  the  products  of  inflammation  which  accumu- 
lated there  before.  This,  with  appropriate  cleansing  and  topical 
applications,  soon  restores  the  mucous  membrane  to  its  normal  con- 
dition, and  the  removal  of  the  redundant  tissue  during  the  operation 
of  closing  the  opening  effectually  cures  the  whole  trouble.  This 
treatment  is  admirably  adapted  to  marked  cases  of  long  standing, 
and  should  be  employed.  By  using  the  thermo-cautery  to  make  the 
opening,  the  operation  is  easily  performed.  In  recent  cases  of  less 
severity,  I  have  obtained  satisfactory  results  by  dilating  the  lower 
part  of  the  urethra,  and  supporting  the  dilated  portion  either  with  a 
pessary  or  a  tampon  of  marine  lint.  This  permits  the  urethra  to 
keep  itself  empty,  and  then,  by  frequently  washing  it  out  and  apply- 
ing such  remedies  as  will  cure  the  urethritis,  recovery  will  sometimes 
follow.  This  treatment  can  be  tried,  and,  if  it  fails,  Bozeman's 
method  can  be  resorted  to.  Dr.  T.  A.  Emmet  has  extended  the 
usefulness  of  this  operation.  He  calls  it  button-holing  the  urethra, 
and  employs  the  operation  for  diagnostic  purposes  as  well  as  for  the 
cure  of  various  affections  of  the  urethra  and  bladder.  I  have  tried 
this  operation  as  faithfully  as  I  could,  and  find  that  it  is  easily  per- 
formed by  using  a  scissors  modified,  but  like  the  button-hole  scissors 
used  by  tailors  (Fig.  247). 


Fig.  247. — Button-hole  scissors  (Skene). 


The  probe-pointed  blade  is  introduced  into  the  ui'ethra,  and  the 
short  blade  into  the  vagina  as  far  as  the  point  at  which  the  opening 
is  to  be  made.  One  clip  usually  is  sufficient,  but  if  a  larger  opening 
be  desired,  it  can  be  made  by  carrying  the  scissors  up  or  down,  and 
dividing  as  much  more  of  the  septum  as  may  be  desired. 

This  operation  is  most  thoroughly  efiicient  for  the  purpose  desig- 
nated for  it  by  Dr.  Bozeman,  and  it  is  also  a  convenient  way  of  re- 
moving neoplasms  situated  in  the  middle  and  upper  thirds  of  the 


OEGANIO  DISEASES   OF  THE   URETHRA. 


861 


urethra,  when  thej  can  not  be  easily  reached  through  the  meatus 
urinarius.  In  regard  to  this  operation,  as  a  means  of  diagnosis,  I 
have  not  been  able  to  discover  that  it  has  any  advantages,  either  to 
the  patient  or  surgeon,  over  the  methods  I  have  already  described. 
On  the  contrary,  so  far  as  simplicity,  safety,  facility,  and  efficiency 
are  concerned,  it  is  very  inferior. 

6.  Dislocations  of  the  Urethra. — This  is  one  of  the  affections  that 
will  frequently  be  met  with  in  practice,  although  very  little  is  said 
about  it  in  text-books.  I  have  found  very  few  cases  recorded  in 
medical  literature.  This  neglect  of  the  subject  by  authors  is  perhaps 
due  to  the  fact  that  in  many  cases  of  displacement  of  the  urethra, 
the  bladder  is  also  dislocated,  and  the  whole  trouble  is  described 
under  the  head  of  vesicocele  or  cystocele.  JSTow  it  is  true  that  dis- 
placement of  the  two  occurs  together,  but  it  will  also  be  found  that 
either  may  take  place  alone.  It  is  not  by  any  means  uncommon  to 
find  prolapsus  of  the  bladder  while  the  urethra  is  in  its  normal  posi- 
tion, and  occasionally  a  case  will  occur  in  which  the  urethra  is  pro- 
lapsed, while  thebl  adder  remains  in  its  proper  place. 

The  urethra  is  subject  to  displacement  upward  and  downward. 
In  pelvic  tumors  the  bladder  is  sometimes  pushed  up  out  of  the  pel- 
vic cavity,  and  the  urethra  dragged  along  with  it.  Usually  no  harm 
comes  from  this  displacement,  except  that  it  may  cause  some  difficulty 
in  using  the  catheter,  should  this  be  necessary ;  hence  I  need  not 
dwell  on  this  part  of  the 
subject.  Dislocations 
downward  are  the  most 
important  because  they 
occur  more  frequently, 
and  almost  invariably 
cause  suffering  to  those 
so  affected. 

Tiie  extent  of  dis- 
placement varies  ex- 
ceedingly, but  I  shall 
describe  only  the  par- 
tial and  the  complete. 
A  clear  comprehension 
of  these  two  degrees 
will  cover  all  interme- 
diate forms.  In  partial 
displacement  downward,  the  upper  two  thirds  of  the  urethra  are  pro- 
lapsed, so  that  the  direction  of  that  portion  of  the  canal  is  backward, 


Fig.  248.- 


-Dislocation  of  the  upper  third  of  the  urethra. 
s,  symphysis  pubis  ;  r,  rectum. 


862 


DISEASES   OF  WOMEN. 


instead  of  curving  upward,  as  in  the  normal  condition.     Fig.  248 
will  convey  the  idea  of  this  degree  of  dislocation. 

In  complete  prolapsus  the  urethra  runs  from  the  meatus  (which 
is  in  its  normal  position)  backward,  and  rests  upon  the  perinaeum ;  or 
in  extreme  cases,  accompanied  with  prolapsus  of  the  bladder  and 
uterus,  its  direction  is  backward  and  downward ;  the  position  of  the 
vesical  end  of  the  urethra  being  below  the  level  of  the  meatus.  In 
this  degree  of  displacement  the  urethra  and  bladder  can  be  seen  pre- 
senting at  the  vulva,  or  lying  between  the  labia  minora  or  thighs. 


Fig.  249. — Complete  .dislocation  of  the  urethra  with  dilatation,     tx,  urethra. 

The  urethra  is  usually  shortened  considerably  when  the  prolapsus  is 
marked.     Fig.  249  illustrates  complete  dislocation. 

Symptomatology. — The  symptoms  arising  from  displacement  of 
the  urethra  are  much  the  same  as  those  found  in  dilatation  and 
other  urethral  diseases.  I  need  not,  therefore,  repeat  them  in  detail. 
Suffice  it  to  say,  that  in  dislocation  of  the  upper  portion  of  the  canal, 
there  is,  in  addition  to  frequent  urination,  a  partial  loss  of  control  of 
the  bladder.  Under  the  extra  pressure  of  coughing,  for  example, 
the  urine  will  escape.  This  loss  of  control  does  not  exist,  as  a  rule, 
in  comjDlete  displacement.  On  the  contrary,  there  is  usually  diffi- 
cult urination,  which  requires  increased  voluntary  efforts  to  empty 
the  bladder.     In  some  cases  the  bladder  can  not  be  emptied  until 


ORGANIC  DISEASES  OF  THE   URETHRA.  863 

it  is  pushed  up  into  position.  In  all  degrees  of  displacement,  the 
symptoms  are  increased  in  the  erect  position,  and  are  markedly  re- 
lieved when  the  patient  lies  down. 

Diagnosis.— Kn  examination  of  the  vagina,  either  by  the  touch 
or  speculum,  will  reveal  the  downward  projection  of  part  or  all  of 
the  urethra,  which  will  demonstrate  that  there  is  either  dilatation  or 
prolapsus.  The  two  conditions  can  then  be  differentiated  by  the  use 
of  the  sound.  The  change  in  the  direction  of  the  canal  will  be 
shown  as  the  sound  passes  in,  and  dilatation  can  be  excluded  by  ob- 
serving that  the  urethra  grasps  the  instrument  firmly  at  all  points. 
In  dislocation  of  the  upper  two  thirds  of  the  urethra,  it  will  be  found 
that  the  sound  passes  in  the  normal  direction,  but  is  arrested  at  half 
or  three  quarters  of  an  inch  from  the  meatus ;  but,  by  pushing  up 
the  vaginal  wall  and  the  urethra,  the  sound  will  then  pass  into  the 
bladder.  When  the  prolapsus  is  complete,  the  instrument  passes  in 
easily,  but  takes  a  downward  and  backward  direction. 

Prognosis.— \Jncom^\\Q,2iiQdi  displacement  of  the  urethra  can  be 
remedied  in  the  great  majority  of  cases,  if  the  trouble  has  not  been 
of  long  standing.  By  placing  the  parts  in  proper  position,  and  hold-  _ 
ing  them  there,  the  relaxed  tissues  will  usually  contract  sufficiently 
to  support  themselves.  Should  they  fail  to  do  so,  the  patient  can  be 
at  least  made  comfortable  by  wearing  some  supporter.  In  many 
cases  the  pelvic  floor  is  imperfect,  and  by  restoring  it  and  bringing 
the  parts  together  high  up  the  urethra  will  be  kept  in  place  by' the 
natural  supports. 

Causation. — Utero-gestation  and  delivery  are  the  most  important 
causes  of  this  affection.  In  the  advanced  months  of  pregnancy  I 
have  observed  that,  while  the  bladder  rose  above  the  pubes,  the 
urethra  was  pushed  shghtly  downward  by  the  settling  of  the  en- 
larged uterus  into  the  pelvis.  In  such  cases,  when  labor  occurs,  the 
head  of  the  child  dislocates  the  urethra  still  more,  by  pushing  it 
still  farther  down.  This  process  I  have  often  watched  in  forceps 
delivery.  When  the  child's  head  is  large,  and  there  is  a  partial  pro- 
lapsus of  the  urethra  existing  before  the  forceps  are  apphed,  one  can 
see  during  traction  that  the  urethra  and  anterior  vaginal  wall  are 
forced  down  before  the  advancing  head,  and  that,  too,  while  counter- 
pressure  to  prevent  it  is  being  made.  The  displacement  produced 
in  this  way  is  often  corrected  during  convalescence,  if  proper  care  be 
taken  to  push  the  parts  back  into  place,  and  the  patient  kept  at  rest 
until  the  tissues  regain  their  tonicity.  But  in  many  cases  the  trouble 
is  overlooked,  and,  by  permitting  the  patient  to  get  up  and  be  on 
her  feet  while  there  is  still  prolapsus,  it  will  slowly  increase,  until 


864  DISEASES   OF   WOMEN. 

tlie  dislocation  is  complete.  This  will  surely  be  the  case  if  there  is 
any  loss  of  perinseura.  Indeed,  nipture  of  the  perinaeura  is  an  acci- 
dent which  permits  the  urethra  to  descend  from  its  place.  I  believe 
that  the  perinaeum  supports  the  vaginal  walls,  which  in  turn  support 
the  urethra ;  and  if  the  perinseum  is  lost,  even  in  pai"t,  the  vaginal 
walls  become  relaxed,  or  perhaps  never  regain  then*  tonicity  after 
delivery,  and,  setthng  down  more  and  more,  carry  the  urethra  with 
them.  I  need  hardly  repeat  what  has  already  been  said,  that  dis- 
placements of  the  uterus  often  cause  malposition  of  the  bladder  and 
urethra. 

Treatment. — "When  the  displacement  of  the  urethra  is  caused  by 
any  other  affection,  such  as  defective  perinaeum  or  jDrolapsus  uteri, 
then  these  things  should  first  be  attended  to.  Should  there  be 
urethritis,  that  also  should  receive  appropriate  treatment.  But  the 
chief  indication  is  to  retain  the  urethra  in  place,  and  this  may  be 
accomplished  by  using  the  pessary  which  has  been  recommended  for 
supporting  the  prolaj^sed  bladder.  Prolapsus  of  the  upper  part  of 
the  urethra  can  be  remedied  in  this  way  quite  satisfactorily.  When 
the  whole  urethra  is  displaced  this  instrument,  while  it  supports  the 
upper  part,  will  still  permit  the  middle  portion  of  the  urethra  to 
settle  down.  This  may  be  remedied  by  making  the  anterior  portion 
of  the  pessary  long  enough  to  engage  in  the  introitus  vulvae,  and  in 
that  way  keep  the  whole  canal  where  it  should  be.  Should  this 
cause  the  patient  much  discomfort  the  vagina  may  be  tamponed 
with  marine  lint,  and  the  parts  kept  in  position  until  the  trouble  is 
partially  overcome,  and  then  the  pessary  will  complete  the  treatment. 

rLLrSTEATTVE    CASE. 

By  way  of  illustrating  what  has  been  said  on  this  subject,  I  will 
give  the  history  of  a  case  which  may  be  accepted  as  a  fair  repre- 
sentative of  such  as  will  oftentimes  be  met  in  practice. 

A  lady,  fifty-seven  years  of  age,  who  had  borne  seven  children, 
and  possessed  excellent  general  health,  was  very  much  troubled  by  a 
partial  loss  of  control  over  the  bladder.  While  at  rest  she  had  no 
difficulty,  but  on  coughing,  laughing,  stooping,  or  lifting  any  heavy 
weight,  the  urine  would  escape  in  spite  of  her  efforts  to  control  it. 
I  found  the  upper  two  thirds  of  the  urethra  displaced  do^^'nward. 
Upon  separating  the  labia,  the  urethra  and  vaginal  wall  presented 
just  within  the  introitus,  like  the  tumor  seen  in  prolapsus  of  the 
anterior  vaginal  wall  or  cystocele.  Introducing  the  catheter,  I  ob- 
served that  it  passed  in  the  usual  direction  for  about  three  eighths 
or  half  an  inch,  and  then  turned  downward  and  backward,  in  the 


ORGANIC  DISEASES   OF  THE   URETHRA.  865 

direction  of  the  liollow  of  the  saciiini,  I  also  satisfied  myself  that 
the  urethra  was  not  dilated,  by  observing  that  it  grasped  the  catheter 
firmly  throughout  its  whole  extent.  It  was  shortened  to  about  an 
inch.  This  I  ascertained  by  slowly  passing  the  catheter  until  the 
urine  began  to  flow,  and  then  withdrawing  the  instrmnent  and 
measuring  from  its  eye  to  the  point  marked  at  the  meatus  uriuarius. 

A  pessary  was  fitted  to  keep  the  parts  in  place,  and  very  marked 
relief  was  at  once  secured. 

From  the  nature  of  the  dislocation,  and  the  very  prompt  relief 
following  the  treatment,  I  am  inclined  to  think  that  the  incontinence 
in  cases  such  as  this  is  due  to  the  settling  down  of  the  upper  por- 
tion of  the  urethra,  by  which  the  pressure  of  the  bladder  and  its  con- 
tents falls  directly  on  the  sphincter  vesica,  and  overcomes  its  resist- 
ing power.  Whether  this  is  the  correct  explanation  or  not,  one 
thing  is  certain,  and  that  is,  that  cases  like  the  foregoing  are  often 
met  in  practice,  and  the  treatment  of  restoring  the  dislocated  urethra 
gives  prompt  relief. 

It  must  not  be  supposed  from  what  has  been  said  about  this  case, 
that  the  partial  loss  of  retentive  power  in  the  bladder  so  frequently 
met  with  in  women  who  have  borne  children,  is  always  due  to  dis- 
location of  the  urethra.  The  following  case  will  illustrate  sufficiently 
well  a  class  whose  symptoms  might  lead  to  the  suspicion  of  disloca- 
tion of  the  urethra  when  it  did  not  exist : 

A  lady,  fifty-five  years  of  age,  the  mother  of  six  children,  con- 
sulted me  on  the  subject  of  her  urinary  troubles.  She  said  that  she 
was  obhged  to  urinate  oftener  than  she  used  to,  and  that  she  could 
not  stand  or  walk  for  any  length  of  time  without  being  annoyed  by 
the  dribbling  of  urine. 

She  was  rather  out  of  health.  Her  digestion  was  labored,  and 
she  was  anaemic  and  easily  fatigued.  Dislocation  of  the  urethra 
was  suspected,  but  upon  examination  the  pelvic  organs  were  all 
in  proper  position  and  free  from  disease,  except  that  there  was  a 
want  of  muscular  tonicity  of  the  peringeum  and  vagina.  The  ure- 
thra was  congested  throughout  its  entire  extent,  and  supersensitive, 
especially  at  its  upper  portion.  There  was  also  some  slight  dilata- 
tion, or  abnormal  dilatability,  of  the  upper  two  thirds  of  the  canal. 

She  was  treated  with  vaginal  injections  of  cold  water,  applica- 
tions of  tannin  in  solution  to  the  urethra,  and  tonics,  including  small 
doses  of  nux  vomica.  As  her  general  health  improved,  the  urinary 
troubles  gradually  left  her.  This  case  properly  belongs  to  the  class 
of  dilatations,  but  is  given  here  to  show  its  resemblance  to  that  of  dis- 
locations. 

56 


866  DISEASES  OF   WOMEN. 

The  failure  (in  certain  cases)  of  all  methods  of  treatment  led  me 
to  devise  the  following  operation  for  the  relief  of  prolapsus  of  the 
urethra.  An  incision  is  made  on  each  side  of  the  urethra  down 
through  the  vaginal  wall,  and  extending  from  half  an  inch  within 
the  vulva  upward  and  outward  an  inch  or  more.  The  edges  of  the 
wounds  are  retracted,  and  with  a  buried  catgnt  suture  the  tissues 
below  the  vaginal  wall  are  drawn  together  and  at  the  same  time 
united  to  the  fascia  which  forms  the  subpubic  ligament.  Another 
row  of  sutures  unites  the  deeper  portion  of  the  vaginal  wall,  and 
the  third  closes  the  surface  portion  of  the  wound. 

1^0  tissue  at  all  is  removed.  The  object  of  the  operation  is  to 
gather  together  the  tissues  on  each  side  of  the  urethra,  and  unite 
them  to  the  fascia  above.     See  Fig.  24r9a,  Plate  lY. 

I  am  unable  to  speak  from  suflEicient  experience  regarding  the 
results  of  this  operation,  but  it  promises  to  be  of  great  value. 

Prolapsus  or  Inversion  of  the  Urethral  Mucous  Membrane. — This 
subject  has  been  already  spoken  of  in  connection  with  urethral 
dilatations,  and  little  more  need  be  said  about  it,  except  to  mention 
that  it  occasionally  occurs  as  a  distinct  affection.  In  fact  the  mem- 
brane can  not  become  inverted  unless  there  is  a  change  in  its  struct- 
ure and  its  relations  to  the  tissues  beneath  it.  Hence  it  must  in  all 
cases  be  a  secondary  affection.  The  membrane  must  be  increased  in 
extent  of  surface,  either  from  relaxation  of  its  fibers  or  hyperplasia, 
and  its  basic  attachments  be  loosened,  before  it  can  be  prolapsed. 
These  changes  are  doubtless  the  result  of  malnutrition  in  the  form 
of  degeneration. 

The  prolapse  may  be  limited  to  one  side,  or  extend  all  around  the 
canal.  The  size  and  extent  of  the  protrusion  varies  considerably. 
If  the  meatus  is  of  full  size,  the  prolapsed  portion  will  usually  pre- 
serve its  natural  color  for  a  time ;  but  after  a  while,  from  chafing 
when  wet  with  urine,  and  especially  if  not  kept  clean,  it  will  become 
red  and  (Edematous.  When  the  meatus  is  small,  these  changes  occur 
sooner  and  in  a  more  marked  degree,  because  the  prolapsed  portion 
is  partially  strangulated. 

The  longer  the  membrane  remains  exposed,  the  more  sensitive  it 
becomes,  and  the  frequency  of  urination  and  pain  attending  it  in- 
creases. It  also  becomes  very  tender  and  painful  to  the  touch.  In 
marked  cases  the  ordinary  movements  of  the  body  irritate  the  parts, 
and  in  that  way  render  walking  painful. 

These  are  symptoms  that  closely  resemble  those  of  irritable 
growths  at  the  meatus  urinarius  ;  and,  so  far  as  history  is  concerned, 
it  will  not  be  possible  to  make  a  differential  diagnosis.     To  do  this  it 


ORGANIC   DISEASES   OF  THE   URETHRA.  867 

is  necessary  to  make  a  local  examination.  The  physical  signs,  and 
tlie  points  in  the  diagnosis  between  this  affection  and  other  diseases, 
have  been  given  briefly  but  sufficiently,  under  the  head  of  dilatations 
of  the  urethra,  and  need  not  be  repeated  here. 

Prognosis. — This  disease  does  not  yield  promptly  to  mild  treat- 
ment, unless  it  is  seen  early  in  its  progress ;  and  if  it  does  yield  to 
mild,  soothing,  and  astringent  applications,  it  is  liable  to  return. 
But  in  case  there  is  no  other  disease  present  that  tends  to  keep  it 
up,  it  can  usually  be  cured  by  surgical  means.  ' 

Causation. — The  causes  of  prolapsus  of  the  urethral  mucous 
membrane  are  numerous,  bilt  those  that  are  best  known  are  long 
continued  congestion,  urethral  and  cystic  irritation,  causing  frequent 
urination,  and  vesical  tenesmus.  Chlorotic  and  greatly  debilitated 
women  are  said  to  be  predisposed  to  it,  as  also  old  prostitutes.  The 
few  cases  that  I  have  seen  were  in  women  over  tifty  years  of  age, 
and  all  of  them  were  weak,  nervous  patients,  who  had  suffered  from 
some  organic  disease  or  functional  derangement  of  the  urinary 
organs. 

When  a  case  is  first  seen  it  is  well  to  remove  any  inflammation  or 
other  complicating  conditions.  The  prolapsed  membrane  should  be 
replaced,  and  the  patient  kept  quiet  in  bed,  to  favor  the  retention  of 
the  parts  in  situ.  Astringents,  such  as  tannic  acid,  alum,  or  persul- 
phate of  iron,  in  a  mild  solution,  should  also  be  used.  Should  these 
fail,  resort  must  then  be  had  to  the  operation  for  removal  of  the  pro- 
lapsed portion  of  the  membrane.  The  methods  of  doing  this  (by 
excision  and  the  therm o-cautery)  have  already  been  described. 

It  only  remains  for  me  to  say  that  Winckel  operates  by  clipping 
off  the  prolapsed  portion  of  the  membrane,  and  then  stitching  the 
internal  edge  of  the  membrane  to  the  edge  of  the  meatus  with  silver 
wire,  allowing  the  sutures  to  remain  in  place  for  from  five  to  seven 
days.  If  the  operation  is  performed  in  this  way  the  patient  must  be 
kept  under  observation,  to  see  if  contraction  of  the  meatus  takes 
place  ;  and  if  it  does,  it  should  be  treated  by  dilatation. 


CHAPTER  XLVIII. 

ORGANIC   DISEASES    OF   THE    URETHRA    (cONTINFEd). 

STRICTURE,    FOREIGN  BODIES,   AND    INCOMPLETE    FISTULA. 

8.  Stricture  of  the  Urethra. — Obstruction  of  the  urethra,  bj  nar- 
rowing of  its  cahber,  is  a  much  less  common  affection  in  the  female 
than  in  the  male  ;  still  it  occurs  sufficiently  often  to  demand  atten- 
tion. There  are  some  facts  in  the  pathology  of  urethral  stricture, 
peculiar  to  women,  which  I  will  first  notice.  Passing  over  congeni- 
tal narrowing  of  the  urethra,  by  simply  saying  that  such  a  malfor- 
mation has  been  seen,  we  tind  that  stricture  is  develoi^ed  in  the 
female,  as  in  the  male,  by  the  deposit  of  inflammatory  products 
beneath  the  mucous  membrane,  which  by  gradual  contraction  con- 
strict the  canal.  Ulceration  of  the  membrane  in  a  marked  degree 
produces  the  same  results.  The  inflammation  and  ulceration  which 
end  in  the  formation  of  stricture  are  usually  specific  in  character ; 
but  the  same  may  follow  from  the  too  free  use  of  caustics,  and  in- 
juries during  childbirth.  Stricture  may  also  be  produced  by  bands 
of  scar  tissue  formed  in  the  anterior  vaginal  wall  and  stretching  across 
the  urethra.  Contraction  of  the  whole  canal  occasionally  occurs  in 
cases  of  vesico-vaginal  fistula  of  long  standing.  There  the  narrowing 
is  simply  the  result  of  disuse.  The  form  of  stricture  that  will  most 
frequently  come  under  observation  will  be  a  contraction  of  the 
meatus  urinarius,  produced  in  many  cases  by  the  too  liberal  use  of 
caustics  in  the  treatment  of  abnormal  growths  at  the  lower  end  of 
the  urethra,  or  from  vulvitis.  This  form  of  stricture  is  the  least 
troublesome,  and  is  easily  relieved.  "When  due  to  the  results  of 
former  urethritis  or  peri-urethritis,  the  walls  of  the  urethra  are 
thickened  and  indurated  at  the  point  of  the  stricture,  and  there  is 
usually  subacute  urethritis,  sometimes  ulceration.  In  tliose  cases 
where  the  cahber  of  the  canal  is  diminished  by  cicatrices  of  the 
vaginal  walls,  and  in  general  contraction  of  the  urethra  in  vesico- 


ORGANIC   DISEASES   OF   THE   URETHRA.  8(19 

vaginal  fistula  of  long  standing,  the  mucous  membrane  may  be  per- 
fectly normal. 

Symptomatology. — Frequent  and  difficult  urination  are  the  chief 
troubles  caused  by  stricture  of  the  urethra.  The  stream  becomes 
smaller,  and  may  be  twisted  or  flat,  but  this  is  rarely  observed. 
Patients,  as  a  rule,  only  notice  that  they  require  to  urinate  more  fre- 
quently and  that  they  have  to  make  more  voluntary  efforts  to 
empty  the  bladder  than  were  necessary  before.  It  will  also  be  found 
in  almost  all  cases  of  stricture,  that  the  subject  has  at  some  previous 
time  suffered  an  injury  at  childbirth,  urethritis,  or  something  to 
which  the  origin  of  the  stricture  can  be  traced.  Great  care  should 
be  taken  to  obtain  the  previous  history  of  cases  in  which  stricture 
is  suspected.     This  will  aid  in  settling  the  diagnosis  and  causation. 

Diagnosis. — A  digital  examination  by  the  vagina,  will  reveal 
thickening  and  induration,  if  the  stricture  is  due  to  that  cause. 
Cicatrices  of  the  vaginal  wall  compressing  the  urethra  can  be  de- 
tected in  the  same  way.  The  use  of  the  sound  will  aid  in  deter- 
mining the  location  of  the  stricture  and  the  extent  to  which  the 
canal  is  contracted.  When  the  stricture  is  at  the  meatus  it  can  be 
found  with  facility,  and  the  size  of  the  opening  can  be  measured 
with  equal  ease ;  but  when  it  is  located  higher  up,  the  largest  sound 
that  can  be  introduced  witliout  force  should  be  passed  up  to  the 
point  of  stricture.  This  will  localize  it ;  then,  by  using  a  sound  that 
will  pass  through  it,  the  extent  of  tlie  constriction  will  be  ascer- 
tained. 

The  affections  which  are  liable  to  be  mistaken  for  stricture  are 
retention  of  urine  or  difficult  urination  from  pressure  on  the  urethra 
by  the  displaced  gravid  uterus,  pelvic  tumors,  and  dislocations  of 
the  urethra.  The  former  can  be  excluded  by  a  vaginal  examination, 
and  the  latter  can  be  detected  by  the  sound,  used  as  I  directed  while 
discussing  the  diagnosis  of  the  dilatations. 

Prognosis. — Stricture  of  the  urethra  usually  yields  very  promptly 
to  treatment  so  that  the  prognosis  is  good.  The  only  exceptions  are 
where  the  stricture  has  existed  in  a  marked  degree  long  enough  to 
cause  dilatation  of  the  ureters  and  disease  of  the  kidneys.  Chronic 
cystitis  or  urethritis  occurring  as  a  result  of  the  stricture,  or  coinci- 
dent with  it,  may  so  complicate  matters  as  to  make  recovery  slow  or 
even  impossible.  In  cases  where  the  whole  urethra  is  contracted 
because  of  the  existence  of  a  vesico-vaginal  fistula  of  long  standing, 
there  inay  be  found  extreme  difficulty  in  restoring  the  tissues  of 
the  urethral  walls  to  their  normal  state. 

TreatTYient. — The  treatment  of  stricture  will  depend  upon  its 


870  DISEASES  OF   WOMEN. 

location  and  cause.  If  it  is  situated  at  the  meatus,  it  can  be  divided 
by  tlie  urethrotome,  or  forcibly  stretched  with  the  dilator.  When 
due  to  bands  of  scar  tissue  in  the  vagina,  they  should  be  divided  at 
several  points,  and  the  urethra  dilated  by  passing  the  sound.  When 
it  is  owing  to  deposition  of  the  products  of  inflammation  in  the 
submucous  tissue,  forcible  and  rapid  dilatation,  as  practiced  on  the 
male  subject,  will  answer  well  if  the  proper  cases  for  this  form  of 
treatment  are  selected.  While  operating  in  this  way  the  dilatation 
should  be  made  carefully,  with  a  view  to  breaking  up  the  constrict- 
ing tissue  without  lacerating  the  mucous  membrane.  To  do  this  it 
is  not  necessary  to  dilate  the  urethra  to  any  great  extent.  As  soon 
as  it  is  recognized  that  the  stricture  has  given  way,  the  dilatation 
should  be  suspended. 

Incising  the  stricture  from  within  outward,  according  to  the 
method  commended  by  Otis  and  others,  for  the  cure  of  stricture  in 
the  male,  will  no  doubt  answer  a  good  purpose.  In  fact,  I  am  in- 
clined to  believe  that  this  plan  of  treating  the  affection  is  the  best ; 
but  my  own  experience  with  this  operation  on  the  female  urethra  is 
not  sufficient  to  warrant  my  speaking  positively. 

In  contraction  of  the  whole  urethra,  arising  from  disuse  in  cases 
of  vesico-vaginal  fistula,  gradual  dilatation  with  graduated  sounds 
answers  very  well.  This  should  be  attended  to  before  closing  the 
opening  in  the  bladder.  In  all  cases,  attention  should  be  given  to 
any  inflammation  that  may  accompany  the  stricture  or  follow  the 
treatment.  It  is  well  also  to  keep  such  patients  under  observation 
and  pass  the  sound  from  time  to  time  to  see  if  there  is  any  ten- 
dency for  the  stricture  to  return. 

Stricture  at  the  Jimction  of  the  Urethra  and  Bladder. — I  desire  to 
direct  special  attention  to  this  form  of  stricture  because  it  is,  so  far 
as  I  know,  peculiar  to  women,  and  its  influence  on  the  function  of 
the  bladder  has  not  been  pointed  out.  In  fact,  no  distinction  has 
been  made  between  the  pathology  or  clinical  history  of  stricture  at 
the  upper  end  of  the  urethra  and  elsewhere  in  the  canal.  At  least, 
I  am  not  aware  that  writers  on  this  subject  have  mentioned  this 
form  of  stricture.  My  own  observations  on  this  subject  have  been 
limited,  but  sufficient,  I  think,  to  warrant  me  in  saying  that  strict- 
ure does  occur  at  the  junction  of  the  bladder  and  urethra,  and  that 
it  behaves  differently  from  ordinary  stricture  at  other  parts  of  the 
canal. 

From  the  study  of  tlie  cases  which  have  come  under  my  notice, 
I  have  been  led  to  tbe  conclusion  that  stricture  at  this  point  may  be 
produced  by  the  causes  wbich  give  rise  to  the  same  affection  else- 


ORGANIC   DISEASES  OF  THE   URETHRA.  8T1 

where.  The  upper  portion  of  the  urethra  is  liable  to  the  same  trau- 
matic affections  and  inflammatory  troubles  as  the  rest  of  the  urinary- 
organs  ;  and  the  same  products  or  results  of  disease  which  cause 
stricture  of  the  other  portions  of  the  urethra  act  just  the  same  at 
the  point  in  question.  I  need  not,  therefore,  dwell  on  the  anatomi- 
cal lesions  found  in  this  affection.  The  point  of  most  importance 
to  wliicb  I  desire  to  call  particular  attention  is  the  fact  that  stricture 
at  this  part  of  the  urethra  will  cause  difficult  urination,  which  is 
out  of  proportion  to  the  extent  of  the  narrowing  of  the  canal.  In 
other  words,  thickening  of  the  tissues  at  the  union  of  the  urethra 
and  bladder,  with  contraction  of  the  canal  in  a  slight  degree,  will 
cause  great  difficulty  in  urination,  and  frequently  retention.  This  is 
contrary  to  the  history  of  stricture  of  the  urethra  at  other  points. 
In  such  cases  there  is  no  retention  of  urine  until  the  stricture  closes 
the  canal,  or  very  nearly  so ;  but  I  have  seen  retention  in  cases  of 
stricture  at  the  neck  of  the  bladder  while  a  medium-sized  catheter 
could  be  passed  with  ease ;  thus  showing  that  the  narrowing  of  the 
canal  was  not  the  only  cause  of  the  deranged  function.  It  would 
appear  that  the  change  in  structure  of  the  tissues  prevented  the  nor- 
mal action  of  that  portion  of  the  canal  which  performs  the  function 
of  a  sphincter  vesicae.  In  discussing  the  anatomy  and  function  of 
the  bladder  and  urethra,  I  stated  that  the  process  of  closing  and 
opening  the  neck  of  the  bladder  was  not  fully  understood,  and  I 
must  acknowledge  a  like  difficulty  in  explaining  the  disturbance  of 
function  which  is  caused  by  partial  stricture  at  this  point.  Spas- 
modic stricture  suggests  itself  as  the  explanation  of  the  symptoms 
presented  in  such  cases ;  but  it  is  excluded  by  demonstrating  the 
presence  of  organic  narrowing  of  the  canal. 

Symptomatology. — The  symptoms  presented  in  this  form  of 
stricture  are  difficult  urination,  and  in  some  cases  complete  retention. 
I  have  also  noticed  in  one  case  that  there  was  a  frequent  desire  to 
urinate ;  but  that  was  accounted  for  by  a  slight  catarrh  of  the  blad- 
der. 

These  symptoms  are  such  as  occur  in  other  conditions,  such  as 
atrophy  and  paralysis  of  the  bladder;  obstruction  of  the  urethra 
from  tumors ;  calculi ;  or  the  pressure  of  the  displaced  uterus  and 
prolapsus  of  the  bladder.  The  affection  can  not,  therefore,  be  de- 
tected from  the  phenomena  presented. 

Diagnosis. — In  this  form  of  stricture  there  is  thickening  and 
induration  of  the  neck  of  the  bladder,  which  may  be  detected  by 
digital  examination  of  the  vagina.  The  sound  will  also  reveal  a 
narrowing  of  the  canal  at  the  vesical  neck,  but  the  contraction  may 


872  DISEASES   OF  WOMEN. 

not  be  marked.  Main  reliance  must  be  jjlaced  upon  ths  exclusion 
of  all  other  conditions  whicb  can  produce  the  same  symptoms. 
Pressure  upon  the  urethra  and  prolapsus  of  the  bladder  can  be  ex- 
cluded by  an  examination  of  the  jDelvic  organs ;  and  the  use  of  the 
sound  will  show  anything  Kke  a  complete  obstruction  of  the  canal. 

Having  cleared  away  the  possible  existence  of  either  of  these 
conditions,  I  come  to  the  two  affections  which  are  most  likely  to  be 
confounded  with  this  form  of  stricture,  viz.,  atrophy  and  paralysis 
of  the  bladder.  To  distinguish  these  from  the  stricture,  the  cathe- 
ter should  be  passed  when  the  bladder  is  well  distended,  and  the 
character  of  the  flow  of  urine  watched,  when  it  will  be  observed 
that  in  strictm'e  the  urine  comes  away  with  the  usual  force.  The 
bladder  contracts  normally,  and  with  its  natural  vigor,  and  expels 
the  urine  in  a  well-sustained  stream  through  the  catheter  if  there  is 
stricture.  On  the  other  hand,  in  paralysis  and  atrophy,  the  stream 
is  slow  and  without  force,  so  much  so  that  voluntary  effort,  or  the 
pressure  of  the  hand  on  the  abdomen,  is  sometimes  necessary  to 
empty  the  bladder.  This  is  especially  so  when  the  catheter  is  used 
while  the  patient  is  in  the  recumbent  position.  Finally,  the  diag- 
nosis is  contirmed  by  testing  the  dilatability  of  the  urethra.  This 
can  be  done  by  passing  a  dilator  along  the  urethra,  and  gently  test- 
ing the  resistance  of  the  walls  of  the  canal.  In  this  way  a  slight 
yielding  can  be  observed  at  all  points  until  the  stricture  is  reached, 
and  then  decided  resistance  will  be  encountered.  By  careful  atten- 
tion to  these  points  in  the  investigation,  I  believe  it  will  be  possible 
to  make  a  diagnosis  with  reasonable  certainty. 

ILLUSTRATIVE   CASES. 

A  lady,  aged  thirty-two  ;  married  fourteen  years,  and  has  had 
three  children  ;  the  eldest  twelve  years  and  the  youngest  four  years  of 
age.  Thirteen  years  ago  she  had  typhoid  fever,  and  during  the  fever 
had  retention  of  urine,  which  necessitated  the  use  of  the  catheter 
for  about  two  weeks.  After  recovering,  she  was  able  to  empty  the 
bladder  without  difficulty,  but  she  suffered  from  frequent  and  pain- 
ful urination.  After  the  birth  of  her  second  child,  eight  years  ago, 
her  bladder  trouble  became  much  worse,  and  she  has  been  obliged  to 
use  the  catheter  almost  daily  ever  since.  When  comparatively  free 
from  pelvic  pain  and  tenderness  (a  relief  that  she  seldom  enjoys  ex- 
cept for  a  few  days  at  a  time)  she  can  empty  the  bladder  by  making 
strong  voluntary  efforts ;  but  the  rule  is  that  she  is  obliged  to  use 
the  catheter  about  every  four  or  five  hours.  The  bladder  and  ure- 
thra were,  upon  examination,  found  to  be  in  their  normal  positions, 


ORGANIC  DISEASES   OF  THE   URETHRA.  873 

but  there  were  thickening  and  induration  of  the  tissues  at  the  union 
of  the  urethra  and  bladder.  A  'No.  10  (Eng.)  sound  passed  easily 
up  to  the  neck  of  the  bladder,  where  it  was  arrested.  A  No.  8 
(Eng.)  sound  was  then  used,  and  it  entered  the  bladder  after  encoun- 
tering a  little  resistance  at  the  point  named.  The  catheter  was  then 
introduced,  and  the  urine  flowed  freely  and  rapidly,  the  bladder  con- 
tracting promptly  and  with  its  normal  vigor.  While  the  instrument 
was  still  in  place,  a  vaginal  examination  by  the  flnger  was  made,  and 
the  enlargement  and  induration  of  the  urethral  wall  were  distinctly 
felt.  Dilatation  of  the  urethra  was  then  tried,  and  the  canal  yielded 
readily  at  all  parts  except  at  its  extreme  upper  end,  where  it  was 
found  wanting  in  elasticity.  There  was  slight  catarrh  of  the  blad- 
der, as  shown  by  an  excess  of  mucus  in  the  urine.  The  urethra  was 
also  congested.  The  patient  was  very  weak,  nervous,  and  dyspeptic. 
She  was  put  upon  a  course  of  tonic  treatment,  and  the  canal  slowly 
dilated  by  passing  twice  a  week  graduated  conical  sounds,  each  one 
being  allowed  to  remain  in  place  for  five  or  ten  minutes  at  a  time. 
She  improved,  but  when  last  seen  she  still  had  difiiculty  in  passing 
urine. 

Other  cases  might  /be  given  from  my  own  records,  but  I  prefer 
to  present  one,  the  history  of  which  was  given  to  me  by  Dr.  Paul 
F.  Munde.  I  do  not  wish  it  to  be  understood  that  the  only  difiiculty 
in  the  following  case  was  stricture ;  I  only  desire  to  call  attention  to 
the  fact  that  the  patient  had  retention  of  urine  and  also  stricture  at 
the  neck  of  the  bladder.  Still  I  am  aware  that  the  retention  may 
have  been  due  to  some  other  cause — perhaps  paralysis  of  the  blad- 
der. There  are  some  points  in  the  history  of  the  case  which  do  not 
pertain  to  the  question  now  under  discussion,  but  I  will  give  the  full 
record  in  the  doctor's  own  words : 

"Lizzie  C,  twenty-two  years  of  age,  single;  admitted  to  the 
Woman's  Hospital,  December  27, 1876.  Menstruated  first  at  twelve. 
The  menses  since  have  been  irregular,  amount  small,  and  always 
with  pain  in  back  and  hypogastrium,  through  whole  flow  of  two 
days.  General  health  always  good  until  she  had  a  'bilious  attack' 
six  years  ago.  Four  years  ago  the  flow  became  more  and  more 
scanty,  and  finally  ceased  entirely  three  years  ago,  since  which  time 
she  has  not  menstruated  at  all.  Four  years  ago,  after  a  '  bilious 
attack,'  she  had  retention  of  urine  for  three  days,  at  which  time  the 
catheter  was  used.  She  had  several  attacks  of  retention  thereafter, 
at  intervals,  then  micturated  naturally  for  one  year,  but  for  the  past 
three  years  has  not  been  able  to  empty  her  bladder  without  the  aid  of 
a  catheter,  which  she  introduces  herself  habitually  three  times  in  the 


874  DISEASES   OF   WOMEN. 

twenty-four  hours.  She  has  no  desire  to  micturate,  and  can  hold  her 
urine  twenty-four  hours  without  discomfort,  save  a  slight  sense  of 
distention.  She  has  leucorrhoea.  Has  slight  menstrual  molimina 
every  four  weeks,  backache,  hypogastric  pain  and  soreness  in  breasts, 
constant  pelvic  weight  and  dragging.  Bowels  constipated.  General 
health  good.     There  is  now  frequent  nausea. 

"  Physical  Examination. — There  is  anteflexion ;  depth  of  the 
uterus,  two  and  a  half  inches ;  both  ovaries  prolapsed  and  tender ; 
right  enlarged. 

"  Treatment. — Hot  vaginal  douche,  strychnia,  benzoic  acid  ;  later, 
daily  washing  out  of  the  bladder  with  acidulated  warm  water  (ac. 
muriat.  dil.,  gtt.  ij.  to  Oj).  Urine  contains  a  large  quantity  of  mucus 
and  triple  phosphates.  Washing  out  of  bladder  gives  no  relief. 
Phosphoric-acid  mixture  with  ergot  and  iron  was  given  for  months 
with  no  benefit.  Cups  to  lumbar  region ;  galvanic  current  through 
pelvis  twice  a  week. 

"February  3,  1877. — Bladder  washings  omitted,  as  they  caused 
pain.  Large  doses  of  ergot  were  given  for  two  mouths  (the  strychnia 
being  omitted  after  four  months'  trial),  but  without  benefit.  Faradic 
and  galvanic  current  also  used  alternately  every  day  for  months 
without  benefit.  Discharged  unimproved  in  any  way.  May  30, 
1877. 

"Eeadmitted,  October,  1877.  Condition  the  same. 
"October  31. — Urethra  dilated  under  ether;  finger  introduced 
into  bladder,  which  was  found  flaccid,  and  did  not  contract  on  the 
finger,  which,  however,  was  so  closely  constricted  at  the  sphincter 
vesicse  as  to  leave  a  circular  ring  on  the  finger,  the  distal  portion  of 
which  appeared  blue  and  almost  numb  on  being  withdrawn,  after 
about  five  minutes.  During  the  introduction  of  the  finger  the 
greatest  amount  of  opposition  felt  was  at  the  sphincter ;  therefore, 
the  supposition  was  expressed  that  the  retention  might  be  due  to 
spasmodic  contraction  of  the  sphincter  (hysterical  probably,  con- 
nected with  and  dependent  on  the  amenorrhoea,  or  deficient  pelvic 
innervation),  accompanied  by  atony  of  the  detrusor  from  the  same 
causes. 

"  On  examining  the  pelvic  cavity  with  the  finger  in  the  bladder, 
the  left  ovary  was  found  normal  in  position,  but  smaller  than  it 
should  be,  being  about  the  size  of  a  shelled  almond ;  the  right,  how- 
ever, was  distinctly  felt  as  a  globular  body  of  the  size  of  an  English 
walnut.  While  practicing  bimanual  palpation  on  this  ovary,  it 
suddenly  collapsed  under  the  fingers  and  entirely  disappeared,  and 
could  not  be  found  on  careful  palpation.     The  explanation,  doubt- 


ORGANIC  DISEASES   OF  THE   URETHRA.  8T5 

less,  is  that  a  cyst  had  been  ruptured,  and  a  partial  cause  at  least  for 
the  amenorrhcea  was  thus  discovered.  Peritonitic  symptoms  were 
feared,  and  ice  and  opium  given  ;  but,  save  some  suprapubic  sore- 
ness, no  inflammatory  reaction  followed.  Retention  persisted,  and 
urine  had  to  be  drawn  the  afternoon  of  the  dilatation. 

''  November  9. — Goodman's  self-retaining  catheter,  with  rubber 
tubing  attached,  was  introduced  for  the  purpose  of  allowing  the 
urine  to  dribble  off  into  a  urinal,  and  thus  give  the  bladder  a  chance 
to  recover  its  tone.  But  the  catheter  caused  so  much  pain  that  it 
had  to  be  removed  after  several  days. 

"]^ovember  19. — Soft-rubber  catheter  was  introduced,  with  tub- 
ing, etc.,  for  like  purpose,  and  is  now  retained  and  on  trial.  This 
also  caused  pain,  and  was  removed.  Subsequently  vaginal  cystotomy 
was  performed  by  Dr.  Emmet,  but  without  avail ;  and  the  patient, 
after  months  of  ineffectual  treatment,  was  finally  discharged  un- 
cured." 

Treatment. — Regarding  the  management  of  stricture  at  the 
junction  of  the  urethra  and  bladder,  I  am  obliged  to  say  that  my 
experience  has  not  yet  been  sufficient  to  enable  me  to  speak  definitely. 
It  will  be  seen  by  the  history  of  Dr.  Munde's  case  that  rapid  and 
free  dilatation  is  not  sufficient  to  effect  a  cure ;  at  least,  it  did  not 
relieve  his  patient.  Division  of  the  stricture  by  incision  suggests 
itself,  but  I  am  confident  that  that  operation  would  be  unsatisfactory, 
because  of  the  great  irritation  which  always  occurs  when  there  is  a 
solution  of  continuity  at  that  point.  My  practice,  therefore,  has 
been  to  produce  slow  and  gradual  dilatation  by  the  use  of  graduated 
sounds,  and  the  application  of  oleate  of  mercury  or  iodine  to  the 
anterior  vaginal  wall  at  the  site  of  the  stricture.  More  extended 
observation  may  develop  other  and  better  methods  of  treatment,  but 
for  the  present  this  is  all  that  I  have  to  offer  on  this  subject. 

9.  Foreign  Bodies  in  the  Urethra. — Having  treated  at  some  length 
the  subject  of  foreign  bodies  in  the  bladder,  I  shall  confine  myself 
here  chiefly  to  the  practical  points  relating  to  foreign  bodies  in  the 
urethra.  The  character  of  the  bodies  and  their  classification  are  the 
same  as  those  given  while  discussing  foreign  bodies  in  the  bladder. 

Symptomatology. — The  chief  symptom,  if  the  body  be  of  any 
size,  is  retention  of  urine.  In  some  cases  the  obstruction  is  complete, 
in  others  the  urine  comes  away  in  drops.  In  all  cases  there  is  pain 
and  spasmodic  action  of  both  the  bladder  and  urethra.  If  the  body 
be  rough  or  pointed,  it  will  injure  the  urethral  wall,  and  there  will 
usually  be  hasmorrhage,  and  later,  inflammation,  possibly  peri-urethral 
abscess.    If  not  pointed,  but  hard  and  rough,  it  may  ulcerate  through 


876  DISEASES   OF   WOMEN. 

the  urethral  wall,  causing  considerable  haimorrhage.  "When  the 
obstruction  is  kept  up  for  any  length  of  time,  the  greatly  distended 
bladder  becomes  very  painful,  and  may  be  felt  as  a  hard  tumor 
above  the  pubes. 

If  obstruction  occurring  from  this  cause  be  neglected,  such  in- 
juries of  the  bladder  and  kidneys  as  have  already  been  described 
will  ensue. 

Diagnosis. — The  pain  and  retention  will  lead  to  the  examination 
of  the  urethra,  first  by  catheter  or  sound,  and  then  by  the  finger  in 
the  vagina.  In  this  way  the  foreign  body  is  readily  detected,  un- 
less it  be  very  soft,  in  which  case  it  seldom  produces  retention, 
being  usually  washed  out  by  the  urine. 

Treatment. — The  foreign  body  being  detected,  its  extraction 
should  be  attempted  first  by  seizing  it  with  a  pair  of  long-bladed 
forceps,  keeping  it  firmly  in  place  by  a  finger  pressed  on  the 
urethra  through  the  vagina  behind  it.  If  this  is  not  successful,  an 
attempt  may  be  made  to  hook  it  out  with  a  wire  loop. 

I  have  seen  calculi  lodged  in  the  urethra  in  two  cases.  The  first 
one  was  detected  by  using  the  catheter  to  relieve  the  retention  of 
urine,  and  the  other  was  felt  through  the  vaginal  wall,  while  ex- 
ploring with  the  finger  to  determine  the  cause  of  the  pain  in  the 
urethra  and  the  inability  to  pass  water. 

The  first  one,  whicb  was  lodged  near  the  meatus,  was  removed 
as  follows  :  The  forefinger  of  the  left  hand  was  introduced  into  the 
vagina  and  pressed  above  the  calculus  to  steady  it.  A  wire  curette 
was  then  passed  beyond  the  stone  above,  and  by  making  traction 
with  the  curette  and  pressing  with  the  finger  from  above  downward, 
the  body  was  extracted. 

The  other  was  lodged  higher  up  in  the  urethra  and  was  removed 
by  the  saine  method,  except  that  I  used  the  alligator  forceps  instead 
of  the  curette. 

If  it  can  not  otherwise  be  reached  the  urethra  may  be  dilated  up 
to  the  point  where  the  body  is  lodged,  and  then  extracted.  If  ex- 
traction is  impossible,  there  is  a  choice  of  cutting  into  the  urethra 
and  removing  it,  or  of  pushing  it  back  into  the  bladder  and  then 
performing  lithotripsy.     To  me  the  former  seems  preferable. 

10.  Incomplete  Internal  Urethral  Fistula. — This  is  one  of  the 
ratber  rare  affections,  but  it  deserves  a  brief  notice  here,  because 
little  if  anything,  is  said  about  it  in  the  books,  and  it  will  be  very 
likely  met  with  at  some  time  in  the  practice  of  every  physician. 

The  pathology  is  pretty  clearly  indicated  by  the  name.  It  is 
simply  an  opening  in  the  urethra  which  leads  into  the  walls  of  the 


ORGANIC  DISEASES  OF  THE   URETHRA.  877 

urethro-vaginal  septum,  but  does  not  open  into  the  vagina.  It  is 
the  result  of  some  pre-existing  trouble. 

The  causes  which  produced  this  affection  in  the  cases  which  I 
have  seen  (I  recall  only  two  that  have  come  under  my  notice)  were, 
in  the  iirst,  a  peri-urethral  inflammation  which  suppurated  and  dis- 
charged into  the  urethra,  and  in  the  second,  a  cyst  which  formed  in 
the  urethro-vaginal  septum,  which  also  opened  into  the  urethra.  In 
the  first  case,  I  suspect  that  the  patient  had  gonorrhoea  during  preg- 
nancy, and  that  after  confinement  an  abscess  formed  in  the  anterior 
vaginal  wall,  and  opened  into  the  urethra  as  I  have  already  stated. 
The  walls  of  the  abscess  contracted,  but  instead  of  healing  com- 
pletely, there  remained  a  sinus  which  communicated  with  the 
urethra.  This  much  was  inferred  from  the  history  obtained  regard- 
ing its  origin.  When  she  was  first  seen,  the  fistulous  opening  was 
found  in  the  floor  of  the  urethra,  and  it  led  into  the  thickened  and 
indurated  septum  between  the  urethra  and  vagina. 

The  other  case  was  developed  under  my  own  observation  in  the 
following  way.  The  lady  was  pregnant,  and  during  pregnancy 
observed  that  there  was  some  enlargement  just  within  the  introitus 
vaginae.  On  examination,  a  cyst  was  found  in  the  anterior  vaginal 
wall  at  the  middle  of  the  urethra.  She  was  at  the  eighth  month  of 
utero-gestation  when  this  diagnosis  was  made,  and  I  decided  to  let 
the  matter  rest  until  her  confinement.  Immediately  after  the  birth 
of  her  child,  inflammation  was  set  up  in  the  cyst,  and  suppuration 
followed.  An  opening  was  made  into  the  cyst  from  the  vagina, 
and  pus  was  freely  discharged.  At  the  same  time  pus  began  to  flow 
from  the  urethra.  The  discharge  continued  from  both  openings 
for  some  time,  and  then  the  vaginal  opening  closed,  but  pus  con- 
tinued to  flow  from  the  urethra  for  many  weeks.  A  probe  could  be 
passed  from  the  fistulous  opening  in  the  urethra  into  the  sac,  which 
slowly  contracted,  and  finally,  at  the  end  of  six  months,  closed  en- 
tirely, and  the  patient  completely  recovered. 

Symptomatology. — There  is  pain  during  urination,  and  heat  and 
aching  distress  in  the  urethra ;  and  if  the  opening  is  near  to  the 
neck  of  the  bladder,  frequent  urination  and  vesical  tenesmus.  Pus 
is  discharged  from  the  urethra  during  urination,  and  is  found  in  the 
urine.  It  also  oozes  away  at  all  times.  In  some  cases,  the  urine 
enters  the  fistula  and  causes  smarting,  burning  pain  during  and  for 
some  time  after  urination,  by  distending  the  sac  or  burrowing  in  the 
tissues. 

Diagnosis: — Examining  the  vagina  by  the  finger  will  detect  the 
thickening  and  induration  of  the  walls  of  the  urethra  and  vagina  at 


878  DISEASES   OF  WOMEN. 

the  seat  of  tlie  fistula  ;  and  by  making  pressure  with  the  finger  from 
above  downward,  pus  and  urine  can  be  pressed  out,  and  may  be 
seen  as  thej'^  escape  from  the  meatus  urinarius.  A  small  probe  with 
a  bulbous  point  should  be  bent,  so  as  to  make  a  short  curve  at  the 
end,  and  then  passed  into  the  urethra  with  the  curve  directed  toward 
the  floor  of  the  canal ;  and  by  moving  it  to  and  fro  the  fistula  can 
usually  be  found.  The  point  of  the  probe  will  catch  in  the  open- 
ing, and  when  carried  downward  it  can  be  felt  through  the  wall  of 
the  vagina. 

The  only  condition  which  is  liable  to  be  confounded  with  fistula 
is  urethrocele,  but  by  keeping  in  mind  the  physical  signs  of  that  af- 
fection the  distinction  will  be  recognized.  Should  there  be  any 
doubt,  the  endoscope  should  be  used  to  examine  the  urethra.  The 
fistula  will  then  be  found,  and  by  using  the  speculum  the  opening 
can  be  probed  through  it.  A  flexible  gum  catheter  may  be  used  if 
the  silver  probe  does  not  succeed. 

Treatment. — -The  cases  that  have  come  under  my  care  were 
treated  by  washing  out  the  urethra  with  warm  water  and  borax  sev- 
eral times  a  day,  and  keeping  the  sac  emptied  as  completely  as  pos- 
sible by  making  pressure  on  the  urethra,  through  the  vagina,  with 
the  finger.  Both  cases  were  very  tedious,  and  required  much  care 
and  long  treatment.  This  experience  has  satisfied  me  that  the  man- 
agement of  such  cases  ought  to  be  altogether  different  from  that 
which  I  employed.  I  am  confident  that  better  and  more  prompt 
results  would  be  obtained  by  converting  the  incomplete  into  a  com- 
plete fistula.  This  could  be  easily  accomplished  by  passing  a  probe 
into  the  opening  as  far  as  possible,  and  then  cutting  down  upon  it 
through  the  wall  of  the  vagina.  By  this  operation  a  urethro-vaginal 
fistula  is  made,  which  by  proper  treatment  will  close  of  its  own  ac- 
cord. During  the  after  treatment  the  patient  should  wear  a  self- 
retaining  catheter,  or,  what  is  still  better,  have  the  bladder  emptied 
regularlj^  by  the  catheter.  This  will  keep  the  urine  from  getting 
into  the  fistula,  which  prevents  healing.  Care  should  be  taken  to 
keep  the  opening  in  the  vagina  from  uniting  before  the  urethral 
opening  is  healed.  This  can  be  accomplished  by  passing  the  probe 
into  it  from  time  to  time.  The  whole  fistula  should  be  kept  clean 
by  injecting  water  into  the  urethra  and  letting  it  flow  through  the 
fistula  into  the  vagina.  In  case  the  tissues  are  so  indurated  and 
changed  in  character  as  to  refuse  to  heal  under  this  treatment,  the 
fistula  must  be  closed  by  the  usual  operation.  The  method  of  oper- 
ating is  the  same  as  in  vesico- vaginal  fistula,  a  description  of  which 
will  be  hereafter  given. 


CHAPTEE  XLTX. 

DISEASES    OF    THE    GLAJSTDS    OF   THE   FEMALE   TJEETHKA. 

The  diseases  of  these  glands  to  which  I  invite  attention  are : 

1.  Subacute  inflammation  or  catarrh. 

2.  Gonorrhoea!  inflammation  and  its  results  or  products. 

3.  Inflammation  following  vulvitis  such  as  occurs  in  strumous 
children. 

4.  Tuberculosis. 

1.  Catarrhal  Inflammation. — The  first  affection  named  in  the  classi- 
fication is  a  mild  form  of  inflammation  which  occurs  in  connection 
with  subacute  vaginitis,  such  as  we  find  accompanying  ordinary  uter- 
ine disease,  or  folio  wing  parturition.  This  condition  gives  the  patient 
very  little,  if  any,  inconvenience,  and  readily  passes  unnoticed  by  the 
gynecologist  unless  specially  looked  for.  The  mouths  of  the  ducts 
are  slightly  enlarged,  and  sometimes  surrounded  by  a  very  narrow 
areola  of  a  bright  red  color.  By  pressure  upon  the  urethra  from  be- 
hind forward  they  discharge  a  white  serous  fluid.  The  cases  which 
have  come  under  my  observation  were  detected  while  examining  for 
other  diseases,  and  none  of  them  was  attended  with  any  marked 
symptoms.  In  some  of  them  the  inflammation  disappeared  without 
treatment.  In  others  it  continued  without  showing  any  tendency 
to  increase  in  severity  or  lead  to  important  changes  of  structure.  It 
is  quite  possible  that  a  non-specific  vaginitis  might  induce  a  high 
grade  of  inflammation  in  these  glands,  with  all  the  pathological 
changes  to  be  described  hereafter,  but  up  to  the  present  time  I  have 
not  observed  any  evidence  that  such  is  the  case. 

2.  Gonorrhoeal  Inflammation. — This  is  of  the  chronic  purulent 
variety,  and  in  time  extends  from  the  mucous  membrane  of  the 
ducts  to  the  surrounding  tissues.  It  does  not  usually  attract  atten- 
tion until  the  vaginitis  and  urethritis  have  subsided. 

The  lesions  presented  differ  according  to  the  length  of  time  which 
the  disease  has   existed.     When  examined  early  there  is  a   slight 


880  DISEASES   or   WOMEN. 

swelling  of  the  lower  portion  of  the  urethra.  The  months  of  the 
ducts  are  larger  than  normal,  and  the  tissues  around  them  are  con- 
gested. There  is  tenderness  to  the  toucli,  and  pressure  upon  the 
urethra  from  above  downward  causes  a  free  purulent  discharge. 
Sometimes  it  is  necessary  to  separate  the  labia  of  the  meatus  in  order 
to  see  the  orifices  of  the  ducts.  In  cases  of  longer  standing  the 
mouths  of  the  ducts  are  brought  into  view  by  a  slight  prolapsus  and 
aversion  of  the  mucous  membrane  caused  by  swelling.  The  mucous 
membrane  in  the  neighborhood  of  the  ducts  becomes  thickened  by 
proHferation  of  the  areolar  tissue  and  epitheliun^,  presenting  an  ir- 
regular papillomatous  appearance  of  a  deep-red  color,  upon  the  inner 
sides  of  which  the  oriiices  of  the  ducts  appear  like  minute  ulcers, 
of  a  yellowish  gray  color.  The  lower  third  of  the  urethra  is  gener- 
ally thickened  and  indurated.  The  general  appearance  of  the  parts  is 
quite  like  caruncle  or  papilloma  of  the  meatus.  In  fact,  inflamma- 
tion of  these  glands  has  been  mistaken  for  caruncle,  at  least  it  has 
baen  my  misfortune  in  the  past  to  confound  the  two  affections,  and 
1  can  not  see  how  others  could  have  made  a  differential  diagnosis,  if 
guided  by  the  current  literature  upon  the  subject.  In  a  large  propor- 
tion of  the  cases  of  this  disease  I  have  observed  that  upon  the  inner 
sides  of  the  labia  minora,  which  rest  upon  the  meatus,  there  are  patches 
of  inflammation  which  are  caused  and  kept  up  by  the  purulent  dis- 
charge from  the  glands.  These  circumscribed  patches  of  inflamma- 
tion sometimes  extend  downward  on  each  side  of  the  introitus,  and 
oacasionally  involve  the  carunculse  myrtiformes.  This  gives  rise  to 
much  tenderness,  which  simulates  vaginismus.  The  chief  symptoms 
are  extreme  tenderness  to  the  touch,  great  discomfort  in  sitting  and 
walking,  occasional  sharp  stinging  pain,  and  a  continual  sense  of 
heat  in  the  parts.  There  is  painful  urination  in  some  cases,  and  in 
others  there  is  not.  In  some  of  the  most  marked  cases  that  I  have 
seen,  this  symptom  was  entirely  absent,  while  in  less  severe  forms  it 
has  been  present.  That  peculiar  difference  in  the  history  of  cases  I 
have  attributed  to  the  fact  that,  in  the  well-developed  forms  of  the 
disease  there  is  a  considerable  eversion  of  the  lower  portion  of  the 
urethra,  which  throws  the  diseased  and  tender  portion  outward,  and 
thereby  prevents  the  urine  from  coming  in  contact  with  the  irritable 
surfaces.  Occasionally  there  is  frequent  urination,  due  probably 
to  sympathetic  irritation  of  the  bladder.  The  symptom  which  is 
always  present,  in  varying  degrees  of  severity,  is  tenderness.  The 
diagnosis  and  treatment  may  be  left  unnoticed  until  the  other  two 
affections  of  these  glands  have  been  described. 

3.  Purulent  Vulvitis. — This  occurs  in  children,  especially  those  of  a 


DISEASES   OF  THE   GLANDS   OF  THE  FEMALE  URETHRA.  881 

scrofulous  diathesis,  and  occasionally  extends  to  the  urethral  glands. 
When  such  an  extension  of  the  disease  occurs,  it  adds  to  its  well-known 
rebelliousness  to  treatment.  The  original  inflammation  of  the  vulva 
may  be  relieved,  but  if  the  glands  are  involved,  the  purulent  dis- 
charge from  them  will  soon  light  up  the  disease  of  the  external 
parts.  From  my  own  observations  I  believe  that  these  glands  rarely 
become  involved  ;  but  when  they  do,  there  is  little  possibility  of 
curing  the  aiiection  of  the  vulva  until  the  glands  are  first  successful- 
ly treated.  There  is  really  nothing  pecuhar  in  the  clinical  history 
of  this  form  of  disease,  except  its  etiology,  and  therefore  I  need  not 
dwell  longer  upon  it  further  than  to  say  that  I  have  seen  a  case  of 
this  kind,  which  had  resisted  treatment  for  a  long  time,  but  prompt- 
ly recovered  after  the  inflammation  of  the  glands  was  detected  and 
treated. 

4.  Tuberculosis,  or  Tubercular  Inflammation  of  the  Urethral  Glands. 
— This  is  an  affection  to  be  distinguished  from  the  other  forms  of  the 
disease  already  considered.  It  occurs  only  in  those  who  are  of  the 
tubercular  diathesis,  and  may  appear  as  a  primary  affection,  or  be 
developed  during  the  progress  of  tubercular  disease  of  other  organs 
of  the  body.  When  the  disease  is  first  established,  it  presents  the 
same  pathological  appearance  as  has  been  described  under  the  head 
of  gonori'hoeal  inflammation.  There  is,  apparently,  the  same  purulent 
discharge,  with  redness  and  proUferation  around  the  mouths  of  the 
ducts,  giving  the  peculiar  caruncular  or  papillomatous  appearance. 
The  only  peculiar  characteristics  of  this  affection  that  have  been  ob- 
served up  to  the  present  time,  are  the  accumulation  of  caseous  ma- 
terial in  the  tubules  and  ulceration,  which  occur  in  more  advanced 
stages  of  the  disease. 

The  ulceration  takes  place  in  the  newly-formed  tissue  in  the 
walls  and  around  the  mouths  of  the  tubules.  These  caseous  con- 
cretions and  ulcerations  are  not  found  in  all  cases.  Indeed,  they  are 
rare. 

There  is  generally  urethral  inflammation  accompanying  this  con- 
dition of  the  glands.  It  sometimes  begins  simultaneously  with  the 
disease  of  the  glands,  and  when  it  does  not  it  follows  soon  after.  In 
time  the  bladder  becomes  affected,  and  also  the  kidneys.  At  what- 
ever point  the  disease  commences  it  increases  in  severity,  and  ex- 
tends until  the  whole  of  the  urinary  organs  are  involved,  unless  the 
patient  succumbs  before  it  has  completed  its  progress.  In  some 
cases  there  are  polypi  and  papillary  growths  of  small  size  found 
along  the  urethra.  These,  I  believe,  originate  in  inflammation  of 
mucous  follicles  and  papillse  of  the  mucous  membrane. 
57 


882  DISEASES   OF  WOMEN. 

The  symptoms  presented  in  this  form  of  disease  are  the  same  as 
those  found  in  the  other  forms  already  described.  From  this  it  will 
be  observed  that  the  physical  appearance  and  the  symptoms  are  in- 
sufficient to  establish  a  diagnosis.  When  there  are  ulcerations  and 
caseous  deposits  the  disease  may  be  strongly  suspected  of  being  tu- 
bercular. Still,  there  is  room  for  doubt  until  we  find  tuberculosis  of 
other  organs.  This  either  precedes  or  soon  follows  the  appearance 
of  the  disease  of  the  glands. 

In  all  the  cases  which  have  come  under  my  observation,  the 
lungs  were  either  tubercular  when  the  patients  were  first  seen  or 
became  so  soon  after. 

This  afiection  is  a  source  of  great  annoyance  and  suffering,  and 
no  doubt  hastens  the  progress  of  the  pulmonary  disease,  with  which 
it  is  generally  accompanied.  It  has  also  another  very  important 
significance  in  the  fact  that  it  indicates  the  commencement  of  gen- 
eral tuberculosis  of  the  urinary  organs.  The  diagnosis  of  tubercular 
cystitis  and  urethritis  has  always  been  exceedingly  difficult  in  the 
early  stages  of  the  disease.  Indeed,  it  has  been  deemed  impossible 
by  most  authors  to  distinguish  ordinary  cystitis  from  the  tubercular 
form  until  the  disease  became  developed  in  other  organs  of  the 
body.  Now  the  tuberculosis  of  these  glands  is  understood,  a  valu- 
able aid  to  diagnosis  has  been  gained.  Whenever  an  inflammation 
of  these  glands  is  found  that  can  not  be  traced  to  a  former  gon- 
orrhoea or  vulvitis,  it  is  almost  sure  to  be  tubercular,  and  the 
diagnosis  is  placed  beyond  doubt  if  the  patient  has  the  tubercular 
diathesis. 

I  am  greatly  indebted  to  Dr.  Terrillon,  of  Paris,  for  some  very 
valuable  information  upon  the  relations  of  disease  of  tliese  glands 
to  tubercnlosis.  In  the  "  Progres  Medicale "  he  published  a  very 
elaborate  article  entitled  "Polypoid  Excrescences  of  the  Female 
Urethra,  Symptomatic  of  Tubercnlosis  of  the  Urinary  Organs,"  which 
is  full  of  original  observations  of  inestimable  value.  In  comparing 
his  observations  with  my  own,  I  am  fully  satisfied  that  he  has  mis- 
taken tubercular  inflammation,  and  the  products  of  these  glands,  for 
excrescences,  in  some  of  his  cases  at  least.  Without  being  aware  of 
the  presence  of  these  glands,  it  is  perfectly  natural  that  he  should 
class  those  vascular  developments  found  at  the  meatus  urinarius 
among  the  ordinary  neoplasms  of  the  urethra,  just  as  all  others  have 
done  in  the  past.  There  is  every  reason  for  believing  that  the  ex- 
crescences which  Dr.  Terrillon  refers  to  differ  in  their  essential  pa- 
thology from  the  ordinary  polypoid  growths,  usually  called  carun- 
culae,  which  are  found  in  the  urethra  and  are  not  associated  with 


DISEASES  OF  THE  GLANDS   OF  THE  FEMALE    URETRHA.  883 

tuberculosis.  And  as  the  history  of  his  cases  coincides  with  the  his- 
tory of  the  cases  of  tuberculosis  of  these  glands  which  I  have  seen, 
I  am  compelled  to  believe  that  he  has  not  fully  comprehended  the 
true  pathology  of  this  affection.  Pie  has,  however,  clearly  shown 
its  relation  to  tuberculosis  of  tlie  urinary  organs,  and  that  alone  is 
worthy  of  the  highest  honor. 

Dr.  Terrillon's  article  is  too  long  to  be  given  in  full,  but  a  few 
condensed  extracts  will  show  his  views  u]3on  the  subject.  His 
description  of  the  symptoms  and  the  general  appearance  of  the 
parts  affected  is  so  complete  that  I  will  give  it  in  his  own 
words : 

"  The  fungoid  growths  show  themselves  usually  at  the  surface 
of  the  urethral  orifice.  They  are  projecting  and  pedunculate.  Sel- 
dom isolated,  they  form  most  frequently  a  wreath  more  or  less  regu- 
lar, around  the  orifice  of  the  meatus.  In  very  aggravated  cases  they 
are  united  into  a  mass,  and  then  form  a  real  projecting  tumor  with 
a  fringed  aspect,  of  a  lively  red.  In  the  center  of  the  tumor  is  easily 
to  be  found  the  orifice  of  the  urethra  masked  by  those  papillary 
growths.  The  clinical  history  of  fungoid  excrescences  of  the  urethra 
accompanying  tuberculosis  of  that  organ  and  the  bladder  includes 
the  observation  of  two  distinct  parts :  First,  the  study  of  the  growths 
themselves  and  the  character  of  them ;  second,  all  the  phenomena  to 
be  found  in  cystitis  and  tubercular  urethritis.  Sometimes  the  symp- 
toms of  the  two  lesions  are  found  together ;  sometimes  on  the  con- 
trary, they  exist  singly  up  to  a  certain  period  of  the  disease.  One 
of  the  special  symptoms  of  this  affection  is  the  exquisite  tenderness 
of  which  these  fungoids  are  possessed.  The  least  touch,  the  least 
rubbing,  the  passage  of  urine,  suflices  to  cause  the  most  extensive 
pain,  which  renders  life  insupportable.  This  hypersesthesia,  which 
may  extend  to  the  neighboring  parts,  causes,  at  the  sides  of  the  ori- 
fice of  the  vulva,  symptoms  of  the  most  acute  vaginitis.  These  are 
the  ordinary  symptoms  of  fungoid  growths  when  existing  exter- 
nally." The  author  at  this  point  refers  to  excrescences  found 
within  the  urethra  as  being  of  the  same  nature  as  those  found  at  the 
meatus.  He  makes  no  distinction  between  the  two  forms  of  disease. 
There  is,  however,  a  difference  worthy  of  notice.  Excrescences 
found  within  the  urethra  are  usually  cystic  polypi  or  enlarged  pa- 
pillae of  the  mucous  membrane,  conditions  which  may  exist  inde- 
pendently of  tuberculosis.  I  infer  from  some  other  statements  made 
in  his  writings  that  the  granular  urethritis — as  we  are  in  the  habit 
of  calhng  it — is  generally  secondary  to  the  disease  of  the  urethral 
glands.     The  views  of  this  author  in  regard  to  the  order  of  develop- 


884  DISEASES   OF   WOMEN. 

ment  of  urethritis,  cystitis,  and  finally  tuberculosis  of  the  lungs,  are 
set  forth  in  the  following: 

"  Sometimes  at  the  time  of  their  appearance  tliese  fungoids  ap- 
pear to  be  altogether  isolated  from  all  other  serious  lesions.  Yet 
they  seem  to  precede  tuberculization,  or  soon  take  a  rapid  course  in 
developing  granulations  in  the  urethra.  In  other  cases  these  growths 
may  appear  some  time  after  the  symptoms  of  tuberculization  have 
been  established."  The  cases  recorded  by  Dr.  Terrillon,  and  also 
those  which  have  come  under  my  own  observation,  show  that,  as  a 
rule,  this  disease  of  the  urethra  precedes  the  appearance  of  tuber- 
culosis in  other  organs  of  the  body,  such  as  the  lungs.  It  also  is 
one  of  the  first  lesions  observed  in  tuberculosis  of  the  urinary  organs. 
The  following  is  from  Dr.  Terrillon's  paper  on  this  part  of  the  sub- 
ject : 

"!Now  comes  up  the  important  question  whether  these  polypi  of 
the  mucous  membrane  should  be  considered  as  a  primary  or  an  idio- 
pathic lesion,  and  I  think  that  it  can  be  solved  in  the  following  man- 
ner :  These  polypi  are  most  assuredly  the  result  of  chronic  inflamma- 
tion and  an  irritation  of  the  mucous  membrane.  IN^ow,  development 
of  tubercular  granulations  within  the  mucous  membrane  is  at  first 
the  cause  of  irritation  before  any  changes  in  the  urine ;  ulceration 
does  not  occur  until  after  a  sufficient  length  of  time.  With  one  of 
our  patients  the  first  irritation  induced  the  formation  of  polypi,  and 
the  common  painful  symptoms  followed.  Their  extirpation  gave 
relief,  but  that  lasted  only  up  to  the  time  when  urethro-vesical  ulcera- 
tion occurred.  It  will  be  observed  that  in  this  case  the  affection 
began  in  the  urethra  and  extended  to  the  bladder,  and  also  second- 
arily involved  the  left  kidney  (ascending  tuberculosis),  causing, 
finally,  change  in  the  urine,  with  the  free  formation  of  pus.  I  there- 
fore do  not  hesitate  to  maintain  that  the  fungoid  polypi  are  the  result 
of  tubercular  irritation  of  the  mucous  membrane  of  the  urethra, 
which  gives  rise  to  the  very  serious  symptoms  which  occur  in  the 
early  stages  of  the  disease.  Without  them,  urinary  tuberculosis 
would  not  give  rise  to  those  striking  symptoms  until  after  a  sufficient 
length  of  time,  when  the  ulcerations  appear  in  other  organs.  An 
analogous  phenomenon  which  is  observed  in  the  larynx  should  be 
mentioned  here.  We  know,  as  a  matter  of  fact,  that  the  tuberculiza- 
tion of  the  larynx  does  not  only  occasion  ulceration,  but  also  poly- 
poid growths.  There  is  produced  at  the  expense  of  the  ulcerated 
mucous  meuibrane  an  hypertrophy  and  proliferation,  in  the  form 
of  cauliflower  excrescences  or  cockscomb  growths,  a  species  of 
polypi,  smaller  or  larger,  by  which  the  glottis  might  be  more  or  less 


DISEASES   OF  THE  GLANDS   OF  THE   FEMALE   URETHRA.  885 

obliterated.  It  will,  tlierefore,  be  admitted  that  there  is  a  resem- 
blance between  laryngeal  excrescences  and  those  found  in  the  ure- 
thra of  women.  The  polypoid  excrescences  of  the  female  urethra 
are  shown,  from  an  etiological  point  of  view,  to  be  of  two  distinct  va- 
rieties. The  first  variety  is  idiopathic,  and  may  be  recognized  by  a 
slight  irritation.  The  prognosis  is  good ;  extirpation  in  these  cases 
gives  a  rapid  cure.  This  is  the  most  frequent  variety.  The  second 
kind,  although  they  give  the  same  outward  appearance  as  the  first 
variety,  are,  on  the  contrary,  accompanied  from  the  outset  by  ure- 
thritis and  tubercular  cystitis,  of  which  variety  these  lesions  consti- 
tute important  symptoms." 

It  is  clearly  evident  to  me  that  the  two  varieties  described  by 
Dr.  Terrillon  differ  very  essentially  in  their  pathology.  The  first, 
or  simpler  forms  correspond  to  the  papilloma  occasionally  seen,  and 
so  easily  cured  by  extirpation.  The  other  variety  has  its  origin  in 
tubercular  disease  of  the  urethral  glands,  and  is  incurable  by  any 
treatment  heretofore  known,  as  the  author  states. 

Dr.  Terrillon  gives  the  full  history  of  four  cases  observed  by 
him.  They  are  original,  and  of  great  value,  but  too  long  to  be  pro- 
duced here,  Sufiice  it  to  say,  that  in  all  four  there  were  present  the 
excrescences  at  the  meatus  urinarius,  due,  as  their  clinical  histories 
show,  to  disease  of  the  glands,  and,  finally,  tuberculosis  of  the  ure- 
thra, bladder,  and  lungs.  A  careful  post-mortem  examination  was 
made  in  the  fourth  case  observed,  which  revealed  tuberculosis  of  the 
urethra,  bladder,  right  kidney,  and  lungs. 

When  I  found  inflammation  of  these  glands  associated  with  tuber- 
culosis of  other  organs,  it  occurred  to  me  that  the  disease  of  the  glands 
might  be  of  the  same  nature,  or  tubercular ;  but  I  am  indebted  to 
the  writings  of  Dr.  Terrillon  for  the  full  knowledge  of  the  patho- 
logical relations  of  the  affection  of  these  glands  to  tuberculosis  of  the 
other  urinary  organs.  We  have  studied  the  subject  from  different 
stand-points,  and  the  combined  results  of  our  labors  cover  the  ground 
pretty  thoroughly.  While  he  has  clearly  settled  the  relation  of  these 
excrescences  to  tuberculosis  of  the  urinary  organs,  I  have  satisfied 
myself  that  these  new  growths  are  but  the  products  of  a  tubercular 
inflammation  of  the  urethral  glands,  the  existence  of  which  were,  I 
presume,  unknown  to  him.  The  treatment  of  the  various  forms  of 
inflammation  of  these  glands  may  all  be  discussed  at  the  same  time. 

It  is  settled  upon  the  best  evidence  that  when  these  glands  be- 
come inflamed  there  is  no  natural  tendency  to  their  recovery.  Those 
who  have  read  the  history  of  my  first  published  case  will  remember 
that  I  employed  all  the  recognized  treatment  for  caruncle,  but  at  the 


S86  DISEASES  OF   WOMEN. 

end  of  a  year  my  patient  was  no  better.  Dr.  Teirillon  has  had  a 
similar  experience.  On  tliis  point  he  says:  "  A  characteristic  more 
important,  and  to  which  I  desire  to  call  especial  attention,  becaa^e 
it  indicates  well,  in  my  opinion,  the  consecutive  development  of  these 
excrescences,  is  their  tenacity  and  the  facility  with  which  they  recur. 
Really,  one  can  see  in  the  observations'-  (meaning  his  cases)  "in 
which  continued  surgical  intervention  has  been  practiced,  it  brought 
about  either  no  relief  or  only  a  momentary  amelioration." 

The  treatment  which  I  employed  at  lirst  was  to  inject  the  tu- 
bules with  the  ordinary  solutions  used  in  the  treatment  of  inflam- 
mation of  mucous  membranes,  using  for  the  purpose  a  hypodermic 
syringe,  with  the  point  of  the  needle  rounded  off.  This  method  I 
found  useful  but  very  tedious.  It  then  occurred  to  me  that  laying 
open  the  tubules  their  whole  length  and  keeping  them  open  would 
prevent  the  purulent  accumulation  (which  acts  so  effectually  in  keep- 
ing up  the  inflammation),  and  also  bring  the  affected  parts  within 
easy  reach  of  the  necessary  treatment.  This  method  was  suggested 
in  my  paper,  published  seven  years  ago,  and  since  then  I  have  tried 
the  method  in  quite  a  number  of  cases,  and  found  it  entirely  satis- 
factory. In  the  majority  of  cases  it  is  all  that  is  required  to  effect 
a  complete  cure.  The  method  of  operating  is  as  follows :  The  pa- 
tient is  placed  upon  the  left  side,  and  a  Sims's  speculum  used  to  keep 
the  labia  apart  and  retract  the  pei-inoeum.  This  brings  the  parts 
well  into  view,  and  within  easy  reach  of  the  operator. 

The  position  and  depth  of  the  tubules  having  been  first  ascer- 
tained, the  probe-pointed  blade  of  a  very  fine  scissors  is  then  intro- 
duced, and  the  posterior  wall  divided  its  whole  length.  To  prevent 
the  parts  from  reuniting,  a  small  piece  of  cotton,  saturated  with 
persulphate  of  iron,  should  be  packed  in  between  the  divided  edges. 
Brushing  the  surfaces  over  with  the  iron,  without  using  the  cotton, 
will  ans^ver,  although  less  certainly,  to  prevent  reuniting.  Later 
still  in  ray  practice  I  have  opened  these  ducts  M'ith  the  cautery. 
The  method  is  as  follows  :  A  probe  is  passed  into  the  ducts,  and  the 
wall  to  be  di\nded  is  made  tense  by  making  pressure  outward  with 
the  probe.  The  tissues  are  then  divided.  This  method  has  the  ad- 
vantao:es  of  preventing  hfemorrhage,  and  also  of  preventing  the 
parts  from  reuniting.  Very  little  after  treatment  is  ref|uired.  In 
the  majority  of  cases  recovery  follows  the  operation  of  laying  open 
the  canals.  Sometimes  the  inflammation  hngers  in  a  modified  form, 
but  yields  to  a  few  applications  of  nitrate  of  silver  or  sulphate  of 
zinc.  In  several  cases  in  which  the  excrescences  were  abundant, 
they  remained  after  the  operation,  although  very  much  reduced  in 


PLATE   IV. 


FIG.  249  B. 
PAGE  887. 


R.L.D.  DEL. 


PLATE   IV. 

Figure  249?*.     Page  887. 
Inflammation  of  the  Ueetheal  Glands. 

The  hyperplasia  of  the  mucous  membrane  about  tlie  mouth 
of  the  ducts  is  usually  called  caruncle. 

The  red  points  about  the  vulva  show  inflammation  caused 
by  the  discharge  from  the  glands. 


Figure  249a.     Page  806. 
Operation  for  Prolapsus  of  the  Bladder  and  Urethra. 

Incision  on  the  lower  side,  and  buried  suture  partly  intro- 
duced. The  line  on  the  upper  side  shows  the  location  of  the 
incision. 


DISEASES   OF   THE   GLANDS   OF   THE   FEMALE   URETHRA.  887 

size.     An  application  of  nitric  acid  destroyed  them,  and  thej  have 
not  shown  the  least  disposition  to  return. 

ILLTJSTKATIVE   CASES. 

Gonorrhoeal  Inflammation. — The  patient  was  a  married  lady,  thirty 
years  of  age.  She  was  well  developed,  and  had  always  enjoyed 
good  general  health.  With  the  exception  of  a  mild  form  of  dys- 
menorrhoea,  she  had  had  no  disease  of  the  sexual  organs  until  one 
year  before  she  came  under  my  observation.  At  that  time  she  was 
abruptly  attacked  with  a  profuse  leucorrhoea  and  other  symptoms  of 
inflammation  of  the  vulva  and  vagina,  including  painful  urination. 
She  placed  herself  at  once  under  the  care  of  the  family  j)hysician, 
who  treated  her  locally  until  she  came  to  me.  Her  leucorrhoea  had 
by  that  time  diminished,  and  the  painful  urination  had  passed  away, 
but  otherwise  she  had  not  improved.  At  my  first  examination  I 
found  traces  of  the  former  inflammation  of  the  vulva  and  vagina. 
The  meatus  urinarius  was  everted  and  surrounded  by  a  number  of 
papillary  projections,  of  a  deep-red  color,  and  altogether  presenting 
an  appearance  resembling  that  which  is  known  as  vascular  tumor, 
or  carbuncle  of  the  meatus.     See  Fig.  24:9b,  Plate  lY. 

The  diagnosis  then  made  was  subacute  vaginitis,  perhaps  of  gon- 
orrhoeal origin,  and  inflamed  papilloma  of  the  meatus  urinarius. 
The  vaginitis  was  treated  in  the  usual  way,  and  soon  terminated 
in  complete  recovery,  but  the  inflammation  and  tenderness  of  the 
meatus  remained  unchanged,  and  annoyed  the  patient  exceedingly. 
She  could  not  walk  or  sit  without  pain,  and  coitus  had  to  be  avoided 
entirely. 

I  presumed  at  first  that  the  disease  of  the  meatus  was  kept  up 
by  the  irritating  discharge  from  the  vagina,  and  I  hoped  that  when 
the  one  was  removed  the  other  would  get  well,  but  such  was  not  the 
case.  I  then  thoroughly  cauterized  the  elevated  and  tender  points 
about  the  meatus  with  nitrate  of  silver.  This  caused  very  great 
pain  at  the  time,  and  was  followed  by  no  improvement.  Pure  nitric 
acid  was  used  in  the  same  way,  but  with  no  better  result  except  to 
destroy  elevations  of  the  mucous  membrane  around  the  orifice.  The 
same  areola  of  inflammation  around  the  meatus  continued,  and  the 
symptoms  remained  the  same.  A  full  account  of  the  progress  of 
the  case  would  be  tedious  and  useless.  Suffice  it  to  say  that  for 
eight  months  I  treated  the  disease  with  diligence  and  care,  but  at 
the  end  of  that  time  she  was  very  little  better. 

Caustics  and  cauteries  being  unsatisfactory,  I  tried  sedatives  and 
alteratives,  including  iodoform,  iodine,  mercury,  and  bismuth.     At 


888  DISEASES   OF  WOMEN. 

times  tlie  inflammation  subsided  slightly,  and  tlie  elevated  points 
became  smaller,  but  in  a  short  time  fresh  proliferations  sprang 
up  and  the  muco-pm'uleut  secretion  continued  to  bathe  the  parts. 
Toward  the  end  of  this  long  period  of  treatment,  and  while  making 
a  critical  examination,  I  observed  that  on  each  side  of  the  meatus 
there  were  two  depressions  filled  with  a  yellowish  gray  matter,  look- 
ing like  minute  ulcers,  but  upon  probing  them,  with  a  view  to  deter- 
mine their  depth,  I  found  that  they  admitted  the  probe  over  half  an 
inch.  After  withdrawing  the  probe,  I  made  pressure  upon  the  ure- 
thra from  above  downward,  and  succeeded  in  expressing  a  purulent 
fluid,  which  could  be  distinctly  seen  escaping  from  their  ori flees. 
Treatment  was  then  directed  to  these  canals ;  first,  they  were  in- 
jected with  tincture  of  iodine,  and  subsequently  they  were  cauter- 
ized by  passing  a  probe  coated  with  nitrate  of  silver  along  their  en- 
tire depth.  Prompt  improvement  followed  this  application.  The 
inflammation  around  the  meatus  gradually  subsided,  and  the  pain 
and  tenderness  passed  away.  In  less  than  two  months  from  the  time 
that  a  correct  diagnosis  was  made  and  appropriate  treatment  em- 
ployed the  patient  recovered  completely.  The  satisfaction  which 
this  gave  to  both  patient  and  physician  will  be  appreciated  when  the 
fact  is  recalled  that  she  had  been  suffering  for  twenty-one  months, 
and  that  for  nine  months  she  had  been  under  my  treatment  without 
any  marked  improvement. 

Such  was  my  experience  with  this  disease  before  I  knew  any- 
thing about  the  presence  and  character  of  the  structures  involved. 
Since  then  I  have  seen  several  cases  of  the  same  kind,  and  have 
found  the  diagnosis  easy  and  the  treatment  satisfactory.  A  brief 
history  of  another  case  will  contrast  agreeably  with  the  former  one  : 

A  delicate  nervous  lady,  aged  thirty-three  years,  married  seven 
years  without  having  had  children.  She  had  suffered  for  one  year- 
from  symptoms  resembling  those  of  the  case  given  above.  At  flrst 
her  sufferings  were  not  so  severe,  but  in  time  they  became  intoler- 
able, and  she  was  compelled  to  consult  her  physician,  who  exam- 
ined her,  and  found  what  he  supposed  to  be  a  vascular  tumor  of  the 
meatus  urinarius.  He  sent  her  to  me  to  have  it  removed,  I  found 
that  she  had  the  disease  now  under  consideration,  and  a  subacute 
vaginitis  limited  mostly  to  the  upper  and  posterior  portion  of  the  va- 
gina. The  inflamed  papillae  around  the  mouths  of  the  ducts  were 
deep  red,  and  so  tender  as  to  render  it  very  difficult  to  examine  her. 
She  was  directed  to  use  a  vaginal  douche  of  borax  and  warm  water. 
The  inflamed  papillse  were  touched  ^vith  equal  parts  of  tincture  of 
iodine  and  carbolic  acid,  and  the  ducts  were  injected  with  a  solu- 


DISEASES  OF  THE   GLANDS  OF  THE  FEMALE  URETHRA.  889 

tion  of  3  ii  of  nitrate  of  silv^er  to  5  i  of  water.  Twice  a  week  sub- 
sequently they  were  injected  witli  a  solution  of  two  grains  of 
nitrate  of  silver  to  the  ounce  of  water,  and  linally  borax  and  water 
were  used.     Under  that  treatment  she  recovered  in  six  weeks. 

For  injecting  these  ducts,  I  use  a  hypodermic  syringe  with  the 
needle  made  probe  pointed. 

The  history  of  these  two  cases  may  possibly  convey  the  impres- 
sion that  inflammation  of  these  glands  is  easily  cured.  That  is  only 
true  in  some  cases ;  I  have  seen  others  that  were  exceedingly  obsti- 
nate. The  disease  would  subside,  but  not  fully  disappear,  and  as 
soon  as  all  applications  were  suspended  would  return. 

This  has  led  me  to  think  that  other  methods  of  treatment  may 
yet  be  discovered,  and  has  induced  me  to  lay  open  the  ducts  of 
these  glands  in  the  way  already  described. 

Tuberculosis  of  the  Urethral  Glands. — The  first  case  of  this  kind 
which  I  remember  having  seen  came  under  the  care  of  Prof.  E.  1*1. 
Chapman  at  the  Long  Island  College  Hospital  while  I  was  his  assist- 
ant. She  presented  at  her  first  visit  the  history  and  physical  signs 
of  what  was  then  supposed  to  be  caruncle,  which  was  treated  with 
caustics.  Yery  little  relief  followed.  She  soon  gave  evidence  of 
cystitis  which  was  also  treated  for  several  months  without  success. 
The  diagnosis  was  inflammation  of  the  bladder.  After  a  time  she 
disappeared,  but  I  subsequently  learned  that  she  died  in  the  City 
Hospital,  of  pulmonary  tuberculosis.  Upon  reflection  I  am  satis- 
fied that  the  primary  disease  was  tuberculosis  of  the  urethral  glands. 

The  next  case  came  under  my  own  care  in  the  Long  Island  Col- 
lege Hospital.  When  first  seen  she  had  papillomatous  excrescences 
at  the  meatus  and  cystitis,  presumed  to  be  non-specitic.  I  was  at 
that  time  unaware  of  the  presence  of  the  urethral  glands,  and  there- 
fore did  not  at  first  suspect  tuberculosis.  Treatment  gave  her  no 
relief,  and  her  sufferings  were  beyond  description.  In  the  hope  of 
curing  her,  I  made  an  artificial  vesico  vaginal  fistula,  which  relieved 
her  very  much,  but  her  general  condition  became  more  and  more  like 
that  of  a  consumptive.  She  died,  and  a  post-mortem  examination 
revealed  complete  destruction  of  the  left  kidney  from  tuberculosis. 
The  bladder  and  urethra  were  covered  throughout  with  tubercular 
ulcerations.  Since  I  discovered  the  urethral  glands  I  have  seen  two 
cases  of  tuberculosis  affecting  them.  The  history  of  one  of  them 
is  as  follows  : 

A  young  single  lady  first  consulted  me  for  dysmenorrhoea  and 
frequent  and  painful  urination.  I  found  by  examination  that  she 
had  anteflexion  of  the  uterus  and  inflammation  of  the  urethral 


890  DISEASES   OF   WOMEN. 

glands.  The  painful  menstruation  was  partially  relieved  by  correct- 
ing the  flexion.  The  inflamed  glands  were  treated  in  the  manner 
to  be  hereafter  described,  and  the  inflammation  at  that  point  disap- 
peared. Her  frequent  urination  did  not  subside,  however ;  on  the 
contrary,  she  developed  a  marked  cystitis,  which  did  not  yield  to 
treatment.  Her  lungs  at  the  same  time  gave  evidence  of  tubercu- 
losis, which  proved  fatal. 

Recurring  Gonorrhoea  from  Gonorrhoeal  Inflammatio!:  of  the  "Ure- 
thral Glands. — Dr.  H.  C.  Howard,  of  Campaig-n,  Ilhnois,  has  re- 
cently had  a  series  of  cases  in  which  gonorrhoea  had  been  communi- 
cated by  the  husband  to  the  wife,  and  cured  in  both,  but  repeatedly 
returned  in  the  case  of  the  husband,  although  he  had  not  been  im- 
properly exposed.  Careful  examination  of  the  wife  showed  that 
the  disease  had  persisted  in  the  little  glands  of  the  female  urethra, 
flrst  described  by  Dr.  A.  J.  C.  Skene,  of  Brooklyn  ("American 
Journal  of  Obstetrics,"  April,  1880),  and  fully  noticed  editorially  in 
the  "  Chicago  Medical  Gazette,"  May  5,  1880.  Dr.  Howard,  be- 
neving  that  these  little  glands  were  continuing  to  pour  out  true 
gonorrhoeal  pus,  although  the  patient  presented  no  other  evidence 
of  the  disease,  and  that  this  pus  had  produced  recurrent  gonorrhoea 
in  the  male,  directed  his  treatment  to  them,  which  consisted  in  the 
application  of  carbolic-acid  crystals.  In  each  case  the  discharge 
disappeared  permanently  under  this  treatment,  and  the  disease  in 
the  male  now  having  been  cured,  did  not  return.  Dr.  Skene  in  his 
original  paper,  expresses  the  opinion  that  in  the  case  which  he  had 
observed,  the  inflammation  was  caused  by  gonorrhoea,  which  per- 
sisted in  the  glands  long  after  the  original  trace  of  the  disease  had 
disappeared.  Dr.  Howard  seems  to  have  been  the  first  to  note  this 
condition  as  a  cause  of  gonorrhoea  recurring  as  often  as  cured  in  the 
male.  His  observation  is  important  as  showing  that  the  female  may 
communicate  the  disease  long  after  it  would  previously  have  been 
pronounced  cured. —  Chicago  Medical  Review^  August  5. 

After  reading  the  account  of  Dr.  Howard's  cases  I  gave  atten- 
tion to  the  subject  and  found  cases  to  correspond  with  his. 

The  following  is  a  fair  example  and  has  additional  value  because 
confirmed  by  another  observer. 

A  widow  who  had  children  and  was  perfectly  well,  contracted 
a  gonorrhoea  which  ^vas  supposed  to  be  cured.  She  married  again 
and  her  husband  developed  a  gonorrhoea  which  he  supposed  was 
a  recurrence  of  the  disease,  having  had  it  before.  He  was  led  to 
this  conclusion  because  his  wife  had  no  evidence  of  being  simi- 
larly affected.     He  was  treated  by  Prof.  Charles  Jewett  and  soon 


DISEASES   OF  THE  GLANDS   OF  THE   FEMALE   URETHRA.  891 

recovered,  but  again  and  again  the  disease  returned.  Dr.  Jewett 
suspected  that  his  wife  might  have  gonorrhoea  without  the  usual 
acute  symptoms.  He  sent  her  to  me  for  examination.  I  could  not 
find  the  slightest  evidence  of  any  disease  of  the  urethra,  vagina,  or 
uterus,  but  I  noticed  that  the  orifices  of  the  urethral  glands  were 
rather  deeper  in  color  than  normal.  To  make  sure  I  laid  the  ducts 
open,  and  found  pus  in  both  of  them.  They  were  thoroughly  cau- 
terized with  carbolic  acid  and  tincture  of  iodine.  From  that  day 
till  the  present  time,  now  four  years,  there  has  been  no  further  evi- 
dence of  gonorrhoea  in  that  family. 


CHAPTEE  L. 

VESICAL    AXD    UEETHKAL    FISTUX,^. 

Classification  and  Pathology.  —  The  classification  of  fistulse 
which  I  shall  adopt  is  as  follows  : 

I.  Yesico-Yagixal. — This  is  subdivided  into  («)  those  occuiTing 
in  the  trigone,  the  opening  being  situated  at  the  neck  of  the  blad- 
der ;  (b)  those  occurring  at  the  bas  fond,  the  opening  involving  the 
inferior  portion  of  the  bladder. 

II.  UuETHEO-YAGENfAL. — The  Opening  being  between  the  urethra 
and  vagina 

III.  Uteko-Yagixal. — The  opening  communicating  with  the 
bladder,  vagina,  and  cervix,  or  with  the  body  of  the  uterus. 

lY.  In  this  variety  the  entire  vesico-vaginal  wall  is  destroyed, 
and  sometimes  the  urethro- vaginal  wall  also.  This  variety  is  for- 
tunately quite  rare. 

The  relative  frequency  of  these  varieties  is  about  in  the  order  in 
which  they  are  given  in  the  classification.  The  last  and  rarest  one 
is  attended  with  extensi  ve  destruction  of  tissue,  and  includes  the  first 
three  classes.  In  fact,  it  covers  the  ground  occupied  by  all  the  other 
varieties. 

The  direction  of  these  fistulee  may  be  transverse,  oblique,  or 
longitudinal,  and  their  form  may  be  oval,  round,  linear,  angular,  or 
irregular.  The  dimensions  of  the  opening  also  vary  from  one  so 
small  as  barely  to  admit  an  ordinary  probe  to  one  measuring  two 
inches  in  diameter.  The  direction  of  the  fistula  may  possibly  be 
determined  by  the  cause  of  the  primary  injury. 

The  form  of  the  opening  depends  upon  the  arrangement  of  the 
muscular  fibers  of  the  vagina.  This  influences  the  line  of  laceration, 
and  also  the  healing  process,  which  latter  modifies  the  final  shape  of 
the  opening. 

The  condition  of  the  borders  of  the  fistulse  and  their  form  differ 
much  at  first ;  sometimes  they  are  thin,  inverted,  quite  pale,  and 


VESICAL   AND  URETHRAL  FISTULA.  893 

smooth ;  this  is  especially  the  case  with  the  upper  border.  In  other 
instances  they  are  thick,  soft,  and  muscular,  or,  again,  they  may  be 
hard,  inelastic,  and  anaemic.  The  mucous  membrane  of  the  bladder 
often  projects  through  the  opening  if  it  is  large,  forming  a  red  erect- 
ile tumor. 

Symjytomatology. — The  chief  symptom  is  incontinence  of  urine. 
This  is  always  the  same,  no  matter  how  small  or  how  large  the  open- 
ing may  be.  In  some  cases,  indeed,  this  is  the  only  symptom.  In 
others  there  is  much  pain  in  the  pelvic  region,  and  irritation  from 
the  constant  flow  of  urine,  the  pelvic  pain  being  most  marked  at 
first,  and  in  those  cases  in  which  there  is  much  scar  tissue. 

Sometimes  there  is  inflammation  of  the  bladder  and  urethra, 
which  causes  pain. 

If  the  fistula  is  due  to  parturition,  the  state  of  the  bladder  im- 
mediately succeeding  the  labor  is  such  that  for  two  or  three  days 
there  is  an  inability  to  evacuate  its  contents  without  some  pain  or 
uneasiness,  requiring  perhaps  the  use  of  the  catheter.  After  this 
the  urine  may  escape  through  the  urethra,  or  it  may  do  so  from  the 
very  beginning. 

In  from  five  to  ten  days  after  confinement  the  urine  begins  to 
escape  entirely  from  the  vagina.  A  sense  of  something  giving  way 
is  sometimes  felt  at  that  time. 

The  labia,  the  inner  surface  of  the  thighs,  and  the  perinseum, 
being  constantly  bathed  in  the  urine,  become  red,  inflamed,  and  cov- 
ered with  pustules,  which  sometimes  form  ulcers  of  considerable 
depth.  The  external  genitalia  and  the  surface  of  the  vagina  fre- 
quently become  in  crusted  with  a  saline  deposit  consisting  of  urates, 
and  there  is  also  a  strong  urinous  odor  about  the  person  and  the 
clothing  of  the  patient. 

These  symptoms  and  physical  signs,  while  they  are  strong  evi- 
dences of  fistula,  are  not  sufficient  to  base  a  diagnosis  upon.  A  physi- 
cal exploration  of  the  parts  must  be  made  to  ascertain  with  certainty 
the  presence  or  absence  of  a  fistula. 

Physical  Signs. — The  patient  should  be  placed  upon  a  table  in 
Sims's  position  in  a  good  light,  Sims's  speculum  should  be  used  to 
open  the  vagina,  and  the  perinseum  should  be  drawn  well  back 
toward  the  sacrum  until  the  entrance  of  the  air  distends  the  vaginal 

cavity. 

The  fistula,  if  one  exists,  will  most  likely  be  at  once  detected, 
unless  it  is  very  small.  If  it  is  not  found  in  this  way,  a  probe  should 
be  used  to  explore  any  pockets  or  depressions  that  may  exist  in  the 
vaginal  wall.     Should  this  fail,  milk  may  be  injected  through  the 


894  DISEASES   OF   WOMEN. 

uretkra  into  tlie  bladder  to  distend  its  walls,  and  special  attention 
given  to  see  if  any  of  it  passes  into  the  vagina. 

Incontinence  from  some  muscular  lesion  of  the  neck  of  the  blad- 
der, which  allows  the  urine  to  find  its  way  back  into  the  vagina  after 
escaping  passively  from  the  urethra,  is  the  only  affection  which 
simulates  fistula,  but  a  careful  examination  made  in  the  rnanner  just 
described  will  determine  the  diagnosis. 

Complications. — These  are  stricture  of  the  vagina,  recto-vaginal 
fistula,  obliteration  of  the  urethra,  and  cicatrices  of  the  vagina  and 
cervix  uteri.  Inflammation  of  the  edges  of  the  fistula  and  deposits 
of  urinary  salts  in  the  vagina  may  be  present ;  cystitis,  vaginitis,  and 
urethritis  may  also  be  found  accompanying  the  fistulse. 

Prognosis. — If  the  fistula  is  of  such  a  nature  that  it  can  be 
closed  by  an  operation  with  any  reasonable  hope  of  success,  and  in 
the  great  majority  of  cases  this  is  possible,  the  chances  of  a  perfect 
recovery  are  excellent. 

Good  operating  will  generally  insure  success,  except  in  extraor- 
dinary cases,  and  these  are  very  rare. 

Causation. — Pressure  of  the  foetal  head  is  the  most  common 
cause  of  vesico-vaginal  fistula.  Almost  all  authors  agree  in  attribut- 
ing about  ninety  per  cent  to  this  cause. 

Compression  of  the  soft  parts  in  tedious  labor  causes  death  and 
sloughing  of  these  tissues,  and  the  edges  of  the  opening  thus  made 
failing  to  unite,  the  fistulous  opening  results.  If  the  vitality  of  the 
parts  is  not  completely  destroyed,  but  is  greatly  diminished,  inflam- 
mation and  ulceration  may  occur,  and  lead  to  the  same  result  as  in 
the  case  of  sloughing.  The  best  evidence  that  pressure  of  the  foetal 
head  in  delayed  labor  is  the  chief  cause  of  fistula  is  obtained  from 
the  fact  that  since  the  progress  and  improvement  in  the  obstetric 
art,  by  which  difficult  labors  are  more  promptly  terminated,  fistula 
is  far  less  frequent  than  formerly. 

Wounds  of  the  vesico-vaginal  wall  may  occur  during  the  use  of 
instruments  or  long-continued  efforts  in  manual  delivery.  The  slip- 
ping of  a  perforator  in  cases  of  craniotomy  may  be  especially  men- 
tioned as  likely  to  open  the  vesico-vaginal  septum. 

The  forceps  have  come  in  for  a  large  share  of  blame  in  times 
past,  but  they  have  little  agency  in  producing  such  an  accident ;  the 
earlier  and  the  more  frequent  that  they  are  employed  by  educated 
hands,  the  fewer  fistulas  will  occur.  This  is  a  fact  obtained  from 
the  records  of  obstetrics  and  gynecology. 

Foreign  substances  in  the  bladder — vesical  calculi,  for  example 
— may  cause  fistula  by  perforating  the  vesico-vaginal  septum.    Many 


VESICAL  AND   URETHRAL  FISTULA.  895 

years  ago  I  saw  a  case,  with  Dr.  J,  H.  Hobart  Burge,  of  Brooklyn, 
in  whicli  this  happened.  The  first  calculus  formed  in  the  bladder 
was  discharged  through  the  vesico-vaginal  septum,  and  several  more 
were  discharged  through  the  fistula.  Badly  fitting  pessaries,  worn 
for  too  great  a  length  of  time,  may  also  be  mentioned  among  the 
causes  inducing  this  lesion.  Then  there  are  a  number  of  cases  re- 
corded in  which  a  pessary  has  destroyed  the  vesico-vaginal  septum. 
The  process  by  which  the  opening  is  made  is  no  doubt  ulceration 
from  pressure  and  irritation.  The  process  of  ulceration  is  probably 
favored  by  the  deposit  on  the  instrument  of  the  salts  of  the  urine, 
and  the  irregularities  of  this  deposit  produce  destruction  of  tissue. 
There  is  no  doubt  that  this  accident  happened  more  frequently  in 
past  times  when  the  material  used  for  pessaries  was  unsuitable,  and 
the  methods  of  adapting  them  were  not  so  well  understood  as  they 
are  now. 

The  vesico-vaginal  septum  is  often  destroyed  by  malignant  dis- 
ease in  the  advanced  stages,  but  this  does  not  belong  to  the  subject 
on  hand,  and  will  not  be  discussed  here. 

Treatment. — The  treatment  of  fistula  is  either  palliative  or  cura- 
tive by  surgical  means. 

Palliative  treatment  is  little  more  than  an  attempt  to  make  the 
patient  comfortable  by  protecting  her  from  irritation  and  tilth  con- 
sequent upon  the  constant  flow  of  urine. 

The  curative  treatment  includes  the  preparation  of  the  patient, 
the  operation,  and  the  subsequent  management. 

Preparatory  Treatment. — The  operation  for  the  cure  of  fistula 
should  not  be  done  until  after  the  lapse  of  at  least  three  months 
from  the  date  of  its  occurrence.  Some  have  operated  earlier  with 
success,  but  these  early  operations  can  not  be  expected  to  result  suc- 
cessfully. It  requires  at  least  three  months  before  the  system  has 
completely  recovered  from  the  influence  of  gestation  and  parturi- 
tion, and  complete  involution  of  the  sexual  organs  is  secured. 

In  case  of  fistula  the  process  of  involution  is  apt  to  be  delayed 
from  the  local  irritation  and  general  depression  which  usually  attend 
such  injuries.  If  the  patient  is  feeble,  with  loss  of  appetite,  and  is 
nervous,  months  of  preparatory  treatment  may  be  necessary,  con- 
sisting of  good  diet,  fresh  air,  attention  to  the  intestinal  and  other 
secretions,  with  the  use  of  tonics. 

It  is  certain  that  no  one  familiar  with  the  treatment  of  this  form 
of  fistula  will  be  rash  enough  to  subject  his  patient  to  the  incon- 
venience of  such  an  operation  before  attending  to  these  preliminary 
measures.     There  is  no  operation  in  surgery  which   depends  more 


896  DISEASES   OF  WOMEN. 

for  its  success  on  good  general  health  than  this  one.  As  regards  the 
local  treatment,  all  inflammation  must  have  subsided,  and  good  gen- 
eral nutrition  of  the  tissues  about  the  fistula  should  be  secured  in 
order  to  give  a  fair  chance  to  obtain  union  after  the  operation.  To 
secure  all  this,  due  attention  to  cleanliness  should  be  given  and  the 
vaginal  douche  of  hot  water  frequently  employed.  The  excoriation 
due  to  the  urine  flowing  over  the  parts  can  be  relieved  by  Lister's 
ointment  of  boracic  acid.  The  saline  incrustations  which  form  on 
the  edges  of  the  fistula  and  other  parts  can  be  removed  with  the 
forceps,  and  their  reformation  can  be  checked  by  tonics,  the  min- 
eral acids  being  specially  indicated. 

About  one  week  after  menstruation  has  ceased  is  the  best  period 
to  operate.  If  it  is  delayed  until  near  a  menstrual  period  the  anaes- 
thetic which  must  be  given  and  the  irritation  produced  by  the  oper- 
ation itself  are  liable  to  induce  premature  menstruation.  Besides, 
the  tissues  are  in  the  best  condition  to  undergo  the  healing  process 
at  that  time. 

The  complication  most  commonly  met  with  is  stricture  of  the 
vagina  and  scar  tissue  at  the  edges  of  the  fistula.  No  operation 
should  be  undertaken  until  these  are  disposed  of  as  far  as  possible. 
The  methods  of  relieving  stricture  of  the  vagina,  and  also  of  treat- 
ing scar  tissue,  are  by  dividing  the  cicatricial  bands  and  dilating. 

For  a  fuller  discussion  of  this  subject  the  reader  is  referred  to 
the  section  of  this  work  on  cicatrices  of  the  cervix  uteri  and  vagina. 

It  may  be  remarked  that  in  oases  where  the  scar  tissue  can  not 
be  removed  entirely,  the  best  results  are  obtained  by  dilatation  with 
the  tampon. 

OPERATION    FOB.   THE    CURE    OF    FISTULiE. 

An  exceedingly  interesting  chapter  might  be  written  on  the 
many  methods  suggested  and  practiced  to  close  vesico-vaginal  fistula 
but,  while  interesting,  it  would  not  be  sufiiciently  profitable  to  oc- 
cupy time  in  this  connection.  It  may  be  briefly,  yet  comprehen- 
sively, stated  that  all  operations  and  all  methods  of  treatment  tried 
were  failures  until  Dr.  J.  Marion  Sims  by  his  genius  solved  the 
problem.  Furthermore,  it  may  be  stated  that  all  modifications  of 
Sims's  method  suggested  and  practiced  by  others  have  not  been  im- 
provements worthy  of  notice.  A  very  few  changes  of  a  trivial 
character  have  been  made  which  simplify  some  of  the  details  of  the 
operation,  but  beyond  this  the  operation  in  principle  and  practice 
remains  the  same  as  when  given  to  the  profession  by  Dr.  Sims,  to 


VESICAL   AND   URETHRAL   FISTULA.  897 

whom  the  world  is  indebted  for  this  grand  triumph  of  surgical 
science  and  art.     In  describing  the  operation  I  shall  first  give  Snns's 
method  as  closely  as  1  can,  and  then  note  such  slight  changes  as 
have  been  made  by  other  operators.    I  will  be  permitted  to  state  here 
that  before  imdertaking  this  important  operation  the  surgeon  should 
have  acquired  facility  in  the  practice  of  Sims's  methods  of  operating 
upon  the  cervix  uteri  and  vagina.     The  placing  of  the  patient  in  the 
proper  position,  the  management  of  Sims's  speculum  when  held  by 
an  assistant,  and  the  use  of  gynecological  instruments  should  all  be 
familiar  to  the  operator.     The  success  of  the  operation  involves  so 
much  to  the  patient,  that  all  reasonable  efforts  should  be  made  to  se- 
cure success,  and  perfect  operating  is  the  first  essential  to  that  success. 
The  treatment  is  divided  into  four  parts  :  first,  the  placing  the 
patient  in  the  proper  position  and  in  a  good  light ;  second,  the  par- 
ing the  edges  of  the  fistula ;  third,  the  introduction  of  the  sutures 
and  tying  them  ;  and  fourth,  the  after  management.     The  first  pro- 
cedure is  presumed  to  be  familiar  to  the  reader,  but  if  not,  refer- 
ence should  be  made  to  the  chapter  in  which  a  detailed  account  of 
Sims's  position  is  given  and  also  the  management  of  Sims's  speculum. 
The  operation  is  naturally  divided  into  two  parts— first,  paring  the 
edges  of  the  fistula,  second,  passing  the  sutures  and  tying  them. 

The  patient  having  been  placed  in  Sims's  position  upon  the  oper- 
ating table,  and  Sims's  speculum  having  been  introduced,  one  assistant 
holds  the  speculum  while  another  does  the  sponging  and  assists  with 
the  instruments  and  sutures.  A  thoroughly  competent  physician 
should  be  secured  to  give  the  ansesthetic.  Yery  much  depends 
upon  the  patient  being  kept  perfectly  quiet,  and  still  free  from  the 
dangers  of  a  too  profound  ansesthesia. 

Paring  the  Edges  of  the  Fistula.— The  lower  edge  of  the  fistnla  is 
seized  with  a  Sims's  tenaculum  (Fig.  250),  or  a  tissue  forceps  (Fig. 
Yl),  according  to  the 

erator.     Then  with  a  ^        .     o-    ,  .        i 

Fig.  250. — Sims's  tenaculum. 

curved    scissors   (Fig. 

72),  a  strip  is  removed  all  around  the  fistula,  extending  from  the 
mucous  membrane  of  the  bladder  out  upon  the  vaginal  membrane  at 
least  three  eighths  of  an  inch  (Fig.  251).  Care  should  be  taken  not 
to  wound  the  mucous  membrane  of  the  bladder.  It  is  better  to 
keep  unbroken  tlie  piece  that  is  removed  if  possible.  If  upon  "care- 
ful inspection  there  is  any  portion  of  the  vivified  surface  that  is 
not  completely  and  uniformly  pared,  it  should  be  trimmed  until  a 
perfectly  smooth  and  beveled  surface  is  obtained.  Fig.  251  shows 
58 


898 


DISEASES   OF   WOMEN". 


the  beveling  of  the  vivified  edges  of  the  fistula.     The  paring  should 
be  done  with  a  view  also  of  making  the  edges  of  the  fistula,   when 


Fig.  251. —  Operation  for  vesico-vaginal  fistula :  paring  the  edges. 

brought  together,  form  a  straight  or  slightly  curved  line.  The 
direction  of  the  line  of  coaptation  will  of  necessity  depend  upon 
the  size  and  long  diameter  of  the  fistula.  When  it  is  possible,  I 
prefer  to  make  this  line  correspond  with  the  long  diameter  of  the 
vagina,  but  in  case  the  long  diameter  of  the  fistula  is  at  right  an- 
gles to  the  axis  of  the  vagina,  the  edges  must  be  brought  together 
in  that  position.  While  the  surgeon  is  paring  the  edges  the  assist- 
ant sponges  the  wound  with  sponges  held  in  Sims's  long-handled 
sponge-holders  (Fig.  252.) 


Fig  252. — Sims's  sponge-holder. 

When  the  scissors  are  used  to  do  the  paring  there  is  not  much 
haemorrhage.  Occasionally  there  is  troublesome  bleeding  which  re- 
quires to  be  arrested  by  hot  water  either  injected  or  applied  with 
sponges.  This  will  arrest  all  troublesome  oozing,  and  if  any  vessel 
is  found  that  persists  in  bleeding  it  can  be  closed  by  passing  a  cat- 
gut or  silk  suture  under  it  from  the  vaginal  surface  some  distance 
f  ron!  the  vivified  edge. 

Introduction  of  the  Sutures. — Dr.  Sims  employed  silver-wire  sut- 
ures in  this  operation,  and  by  this  he  secured  one  great  element  of 
success.     At  the  time  that  he  introduced  this  metallic  suture  it  was 


VESICAL  AND   UKETHRAL  FISTULA. 


899 


the  only  one  that  was  aseptic  and  without  irritating  qualities,  both 
of  which  were  absolutely  necessary  to  secure  union  in  the  operation. 
Since  that  time  a  better  knowledge  of  all  that  pertains  to  aseptic  and 
antiseptic  surgery  has  made  it  practicable  to  render  silk  as  reliable 
as  the  silver  wire.  I  have  fully  discussed  this  subject  in  the  preced- 
ing pages,  so  that  I  need  only  say  here  that  I  use  the  silk  in  this 
operation.  Long  before  I  had  given  up  silver-wire  sutures,  Simon, 
of  Germany,  had  employed  silk  in  operating  for  vesico- vaginal  fistula, 
and  with  success.  This  fact,  and  my  own  experience,  which  has 
been  just  as  favorable  as  when  I  used  wire  sutures,  lead  me  to  be- 
lieve that  silk  will  be  the  suture  of  the  future,  and  hence  I  will  dis- 
cuss the  exclusive  use  of  it  in  this  operation.  That  the  silk  is  as 
successful  as  silver  wire  I  have  proved  to  my  own  satisfaction  in  many 
cases,  and  it  is  much  more  easily  managed  both  in  the  introduction, 
tying,  and  removal. 
No.  5  braided  silk,  or 
No.  3,  if  the  walls  of 
the  septum  are  thin, 
prepared  as  heretofore 
directed,  is  used   with 

Emmet's  needle.      The  ^i«-  253.— Emmet's  needles. 

length  of  the  needle  varies  according  to  the  thickness  of  the  tis- 
sues to  be  sutured  and  the  fancy  of  the  operator.  The  needle  is 
grasped  in  the  forceps  (Fig.  79),  so  that  the  two  are  at  right  an- 
gles, if  the  line  of  coaptation  is  parallel  to  the  axis  of  the  vagina, 
but,  if  the  line  runs  across  the  vagina,  the  needle  and  forceps  are 
arranged  in  a  line.     The  tissues  are  held  with  a  tenaculum,  and 

the  first  suture  is  introduced  at  the 
angle  farthest  from  the  operator. 
The  needle  is  carried  through  one 
side,  and,  when  its  point  emerges, 
it  is  caught  with  Emmet's  coun- 
ter-pressure instrument  (Fig.  113). 
The  first  suture  is  then  held  by  the 
assistant  who  holds  the  speculum, 
and  this  fixes  the  edges  so  that  the 
other  sutures  can  be  passed  with 
more  facility.  Fig.  255  shows  the 
first  sutures  tied,  and  the  others  introduced.  The  majority  of  sur- 
geons introduce  the  suture  about  half  an  inch  from  the  incision  on 
the  vaginal  side,  and  at  the  edge  of  the  mucous  membrane  of  the 
bladder.     I  much  prefer  to  pass  the  suture  in  a  curved  line  from 


Fir.  254. — The  curved  track  of  the  needle 
b,  bladder  surface :  v,  vasiinal  surface. 


900 


DISEASES   OF  WOMEN. 


one  edge  to  tlie  other  of  the  vivified  surface  (Fig.  254),     If  I  find 
that  this  does  not  draw  the  surfaces  together  with  facility,  I  pass 


Fig.  255.- 


-Operation  for  vesico-vaginal  fistula :  the  sutures  in  place :  method  of  using 
the  counter-pressure  instrument  in  tying  the  sutures. 


Fig.  256 — Two  sutures  tied. 


haK  of  the  sutures  a  quarter  of  an  inch  back  from  the  incised  sur- 
faces, and  then  introduce  superficial  sutures  between  them  to  keep 
the  edges  from  curving  inward  when  the  sutures  are  tied. 

The  method  of  introducing  sutures  was 
fully  described  and  illustrated  in  the  chapter 
on  injuries  of  the  pelvic  floor,  but  so  much 
depends  upon  the  accuracy  with  which  this  is 
accomplished  that  I  refer  to  it  again. 

The  great  point  is  to  make  the  needle 
grasp  more  tissue  in  the  central  portion  of 
the  vivified  surface  than  at  the  edges,  so  that 
when  the  suture  is  tightened  the  opposing  surfaces  will  make  two 
straight  lines  in  place  of  two  concaves,  as  would  be  the  case  if  the 
needle  was  passed  straight  through  the  tissues.  One  can  tell  how 
the  suture  will  tie  by  observing  how  the  free  surface  appears  when 
the  needle  is  in  place.  When  the  needle  is  introduced  completely, 
the  tissues  resting  upon  the  needle  should  give  a  convex  surface. 

The  number  of  sutures  to  be  used  should  be  sufficient  to  bring 
the  edges  accurately  together.  This  requires  that  they  should  be 
about  three  sixteenths  of  an  inch  apart,  if  l^o.  3  silk  is  used.  Hav- 
ing introduced  all  the  sutures,  the  bladder  should  be  thoroughly 
washed  out,  in  order  to  free  it  from  all  blood  that  may  have  accumu- 


VESICAL   AND   URETHRAL   FISTULA.  901 

lated  in  it.  Special  care  should  be  taken  to  make  sure  that  no  blood- 
clot  is  left  in  the  bladder.  The  sutures  should  then  be  tied  in  the 
same  manner  as  has  already  been  described  in  the  directions  for 
restoring  the  cervix  uteri  after  laceration. 

After  Treatment. — The  after  treatment  is  very  simple  indeed, 
as  I  now  conduct  it.  The  patient  is  placed  in  bed,  and,  if  there  is 
pain  of  a  severe  nature,  opium  is  given  to  relieve  it.  This  is  very 
seldom  necessary,  the  pain  being  very  slight,  as  a  rule.  During  the 
first  twenty-four  hours  the  catheter  is  passed  every  four  or  six  hours, 
and  oftener  if  the  patient  has  a  desire  to  urinate ;  after  that,  she  is 
allowed  to  urinate  when  she  desires  to  do  so.  If  there  is  vomiting 
after  the  anaesthetic,  sips  of  hot  water  are  given.  The  tampon  is 
removed  on  the  second  day,  and  the  bowels  are  moved  by  enema  on 
the  third  day.  I  keep  the  patient  in  bed,  but,  after  the  first  twenty- 
four  hours,  she  is  permitted  to  change  her  position  whenever  that 
is  necessary  to  secure  her  comfort,  but  she  is  not  permitted  to  leave 
the  recumbent  position.  On  the  eighth  day  the  sutures  are  removed, 
and,  if  the  result  is  perfect,  the  patient  is  permitted  to  gradually 
resume  her  usual  duties.  In  some  cases  there  is  a  slight  cystitis,  in- 
dicated by  the  presence  of  mucus  in  the  urine  and  frequent  urina- 
tion. This  should  be  managed  by  washing  the  bladder  as  directed 
under  the  head  of  the  treatment  of  cystitis. 

The  after  treatment  described  above  is  nearly  the  same  as  that 
practiced  by  Simon,  and  I  am  satisfied  that  it  gives  as  good  results 
as  any.  It  has  also  some  great  advantages.  The  patient  escapes  the 
great  discomfort  of  wearing  the  catheter  and  remaining  absolutely 
in  one  position,  as  she  must  do  if  the  catheter  is  retained.  There  is 
also  much  less  danger  of  cystitis  or  calculus  if  the  catheter  is  not 
retained.  Should  any  one  feel  disposed  to  use  the  catheter,  I  may 
say  that  Sims's  new  style,  as  figured  on  page  251  of  Thomas's  work 
on  "  Diseases  of  Women,"  is  the  best  in  general  use.  I  have  also 
employed  a  soft-rubber  catheter,  which  is  very  comfortable.  It  is 
retained  in  the  bladder  by  passing  around  it  a  piece  of  adhesive  plas- 
ter, to  which  silk  threads  are  attached  and  fastened  to  a  strap  carried 
around  the  waist, 

ILLUSTRATIVE    CASES. 

The  Simplest  Form  of  Vesico-Yaginal  Fistula. — In  the  winter  of 
1886  my  associate,  Prof.  Nilsen,  brought  a  patient  to  my  clinic,  at 
the  !New  York  Post-Graduate  School,  who  had  a  bilateral  lacera- 
tion of  the  cervix  uteri  and  a  vesico-vaginal  fistula  a  quarter  of  an 
inch  in  diameter,  located  in  the  median  line  midway  between  the 
neck  of  the  bladder  and  the  cervix  uteri.     These  injuries  resulted 


902  DISEASES   OF  WOMEK 

from  her  last  confinement,  wliicli  was  a  very  tedious  one.  The  tis- 
sues around  the  fistula  were  in  a  perfectly  healthy  condition.  A 
tenaculum  was  passed  through  both  edges  of  the  fistula  exactly  in  its 
center,  care  being  taken  not  to  include  the  mucous  membrane  of  the 
bladder  in  the  grasp  of  the  instrument.  Traction  was  then  made 
with  the  tenaculum,  which  raised  a  cone-shaped  projection  in  the 
vagina,  the  fistula  being  in  the  apex  of  the  cone.  While  the  parts 
were  held  in  this  position,  the  edges  were  pared  with  one  clip  of  the 
curved  scissors.  The  piece  of  tissue  removed  was  oblong,  with  the 
fistulous  opening  in  its  center.  The  wound  left  was  more  than  an 
inch  long,  and  nearly  three  quarters  of  an  inch  Avide  on  the  vaginal 
side,  while  the  opening  in  the  mucous  membrane  of  the  bladder  was 
not  much  larger  than  before.  At  the  upper  and  lower  angles  of 
the  wound,  a  little  more  tissue  in  the  vaginal  wall  was  removed  with 
the  tenaculum  and  scissors,  and  that  completed  the  vivifying.  Seven 
prepared  silk  sutures  were  introduced  and  tied,  the  bladder  being 
first  washed  out,  and  the  operation  was  completed. 

The  lacerated  cervix  was  then  restored  in  the  usual  way.  The 
two  operations  occupied  less  than  an  hour.  The  patient  was  then 
put  to  bed,  and  she  rested  fairly  well  during  the  night.  About  five 
hours  after  the  operation,  which  was  performed  between  eight  and 
nine  o'clock  in  the  evening,  the  patient  expressed  a  desire  to  urinate, 
and  the  nurse  passed  the  catheter.  After  this  the  patient  passed 
urine  about  every  five  hours  for  the  first  three  days  and  nights,  and 
subsequently  at  longer  intervals. 

There  was  no  other  treatment  except  that  the  patient  was  kept 
in  the  recumbent  position.  At  my  next  clinic,  one  week  afterward. 
Prof.  I^ilsen  removed  the  sutures  from  the  fistula  and  cervix,  and 
found  the  result  perfect  in  both  operations.  When  the  sutures  were 
removed  there  was  scarcely  a  trace  of  the  point  of  union  where  the 
fistula  had  been. 

Vesico-Vaginal  Fistula  closed  by  turning  into  it  the  Cervix  Uteri. 
(By  D.  Hayes  Agnew,  M.  D.) — A.  M.,  an  Irish  woman,  about  thirty 
years  of  age,  during  a  severe  labor  with  a  first  child  ruptured  her 
uterus,  the  child  escaping  into  the  abdomen.  The  foetal  head  had 
not  passed  below  the  superior  strait  of  the  pelvis,  the  diameters  of 
which  were  contracted.  The  case  being  under  the  care  of  the  medi- 
cal officers  of  the  Nurses'  Home,  Dr.  E.  Wilson  was  immediately 
summoned  to  her  aid  by  the  attending  physician.  Dr.  Scholfield. 
The  propriety  of  the  abdominal  section  admitted  of  no  question. 
The  operation  was  accordingly  performed  by  Dr.  William  B,  Page, 
the  child  removed  through  the  parietes  of  the  abdomen,  and  the  life 


YESIOAL  AND   URETHRAL  FISTULA.  903 

of  the  motlier  preserved.  Some  time  afterward  it  was  discovered 
that  the  rent  in  the  uterine  walls  had  extended  through  the  cervix, 
and  involved  the  vagino-vesical  septum,  giving  rise  to  a  fistula. 
After  the  restoration  of  the  woman's  general  health,  she  was  placed 
in  St.  Joseph's  Hospital,  and,  at  considerable  intervals,  three  unsuc- 
cessful attempts  were  made  to  close  up  the  orifice,  which  was  situ- 
ated near  the  cervix  uteri,  and  running  in  an  obhque  direction,  about 
three  quarters  of  an  inch  in  extent.  Two  of  these  operations  were 
skillfully  performed  by  the  Bozeman  method,  employing  as  a  retent- 
ive mechanism  a  lead  plate  or  button.  The  patient  was  afterward 
placed  in  the  Philadelphia  Hospital  under  my  charge,  where,  after 
some  preliminary  treatment  to  improve  her  general  condition,  she 
was  operated  on  by  the  usual  method,  seven  silver  sutures  being 
required  to  close  it  properly.  On  the  eighth  day  the  stitches  were 
taken  out,  and  the  wound  found  to  be  only  one  haK  closed.  On 
carefully  examining  the  parts  and  reflecting  over  the  former  failure, 
I  thought  I  discovered  the  true  source  of  difiiculty,  which  subse- 
quent events  confimied.  The  proximity  of  the  fistula  to  the  cervix 
uteri,  the  latter  organ  being  somewhat  retroverted,  prevented  an 
accurate  adjustment ;  indeed,  the  os  was  turned  into  the  fistulous 
opening,  and  pressed  toward  the  bladder.  Profiting  by  this  observa- 
tion, at  the  second  operation,  undertaken  nine  weeks  subsequently, 
I  determined  to  turn  the  os  into  the  opening  permanently.  With 
this  end  in  view,  the  inferior  semi-circumference  of  the  fistula  was 
well  pared.  IN^ext,  the  posterior  half  of  the  cervix  uteri,  after  which 
eight  silver  sutures  were  introduced  and  secured  by  the  shot,  the 
ends  of  the  wire  being  cut  oif  close  to  the  latter.  The  os  uteri  was 
by  this  method  turned  into  the  bladder.  ISTothing  worthy  of  note 
transpired  during  the  subsequent  progress  of  the  case.  On  the 
eighth  day  following  the  operation  the  parts  were  examined  with  a 
view  to  remove  the  ligatures,  which  were  found  in  such  excellent 
position,  without  any  surrounding  irritation,  that,  at  the  suggestion 
of  Dr.  E.  Wilson,  who  rendered  me  valuable  service  in  both  opera- 
tions, I  was  induced  to  allow  them  to  remain  for  two  days  longer. 
On  the  tenth  day  they  were  clipped  out,  and,  to  our  great  satisfac- 
tion, the  fistula  closed.  Since  that  time  this  woman  has  menstruated 
regularly  through  the  bladder. 

Vesico- Vaginal  Fistula  and  Closure  of  the  Urethra  from  Inflamma- 
tion.   (By  D.  Hayes  Agnew,  M.  D.) — Catharine ,  a  young  woman 

aged  nineteen  years,  was  seized  with  labor  pains,  September,  1858, 
at  the  Philadelphia  Hospital.  In  consequence  of  the  great  size  of 
the  foetal  head,  it  became  (t)mpletely  impacted  in  the  pelvic  cavity. 


904  DISEASES   OF  W0ME:N". 

After  ineffectual  efforts  to  deliver  with  the  forceps,  the  operation  of 
craniotomy  was  resorted  to  by  Dr.  R.  K.  Smith,  chief  resident  phy- 
sician, and  the  child  readily  removed.  In  consequence,  however,  of 
the  prolonged  pressure  sustained  by  the  anterior  wall  of  the  vagina^ 
a  slough  in  a  few  days  separated,  opening  a  communication  between 
that  cavity  and  the  bladder,  through  which  the  urine  flowed.  An 
examination,  some  weeks  after,  showed  not  only  the  existence  of  this 
fistula,  but  the  canal  of  the  urethra  closed  by  inflammatory  deposit. 
A  trocar  was  at  once  carried  through  the  obstructing  material  into 
the  bladder,  followed  by  a  catheter,  which  was  retained  for  eight 
days,  only  being  removed  for  the  purpose  of  cleansing.  In  this 
manner  the  urethra  was  restored. 

On  the  16th  of  December  following,  the  parts  having  become 
sufiiciently  callous,  an  operation  was  performed  for  her  cure,  her 
bowels  being  well  opened  the  day  previous,  after  which  one  grain 
and  a  haK  of  opium  was  administered. 

She  was  placed  under  the  influence  of  a  mixture  of  ether  and 
chloroform,  turned  upon  her  abdomen  over  a  stool  well  protected, 
the  limbs  being  supported  by  two  assistants,  and  the  parts  exposed 
by  a  Sims's  speculum.  The  fistula,  which  was  transverse  through 
the  trigone  vesicae,  and  exceeding  an  inch  in  its  greatest  diameter, 
could  now  be  well  seen.  The  edges  were  seized  with  the  long  rat- 
toothed  forceps,  and,  with  a  long,  straight,  sharp-pointed  bistoury, 
pared  in  their  whole  extent.  Seven  needles,  slightly  curved  at  their 
points,  each  armed  with  a  silver  thread,  were  carried  successively, 
by  means  of  the  needle-holder,  through  the  edges  of  the  wound  down 
to,  but  not  into,  the  vesical  mu.cou8  membrane.  These  sutures,  being 
brought  out  of  the  vagina,  were  passed  through  the  adjuster  in  suc- 
cession, and  drawn  upon  as  the  latter  was  passed  down,  thus  approxi- 
mating the  edges  very  completely.  Perforated  shot  were  next  run 
down  over  the  wires,  and  clamped  by  means  of  the  compressor.  The 
sutures  were  now  twisted  together,  and  passed  through  a  small  tube 
of  rubber  to  protect  the  parts,  and  the  catheter  carried  into  the  blad- 
der, to  which  was  attached  a  flexible  piece  of  gum-elastic  tubing, 
designed  to  convey  the  urine  into  a  bottle  properly  placed  between 
the  limbs  of  the  patient  for  its  reception.  The  patient  being  placed 
in  bed,  an  anodyne  was  administered ;  the  whole  time  consumed, 
including  etherization,  did  not  exceed  one  hour.  Everything  pro- 
gressed favorably  until  the  third  day,  when,  notwithstanding  opium 
had  been  given  to  keep  the  bowels  in  a  quiescent  state,  diarrhcea, 
attended  with  considerable  straining,  came  on,  but  which  was  at 
length  controlled  by  enemata  of  laudanum.     To  make  the  case  more 


VESICAL  AND   URETHRAL  FISTULA.  905 

embarrassing,  a  cougli,  which  she  had  been  troubled  with  for  some 
time  previous  to  the  operation,  liarassed  her  so  much,  notwithstand- 
ing the  free  administration  of  opium,  as  sometimes  to  drive  the  cath- 
eter out  of  the  bladder. 

On  December  2Tth,  ten  days  after  the  operation,  the  sutures  were 
removed,  and  the  wound  found  to  have  united  save  at  one  single 
point,  which  was  subsequently  and  permanently  closed  by  a  single 
stitch.  The  catheter  was  kept  in  the  bladder  a  few  days  longer,  in 
order  not  to  endanger  the  cicatrix.  This  patient  was  watched  with 
great  care  by  Drs.  Darby,  Richardson,  and  Taylor. 

Fistula  complicated  with  Laceration  of  the  Anterior  Wall  of  the 
Cervix  Uteri.  (By  T.  A.  Emmet,  M.  D.) — Ann  Murphy,  a  native  of 
Ireland,  aged  forty-one,  was  admitted  to  the  hospital,  October  5, 
1864,  from  the  city. 

In  May,  1857,  she  had  been  discharged  cured  from  the  hospital 
after  an  operation  by  Dr.  Sims  for  the  relief  of  a  utero-vesico- 
vaginal  fistula,  resulting  from  a  laceration  directly  through  the  an- 
terior lip  into  the  base  of  the  bladder.  Nine  months  after  her  dis- 
charge, she  had  a  miscarriage  at  the  third  month,  and  a  year  after 
the  last,  another  at  two  months. 

In  her  second  pregnancy,  at  full  term,  labor  commenced  by  a 
sudden  rupture  of  the  membranes  on  Tuesday  evening,  December, 
1861.  Until  9  p.  m.  of  the  Thursday  following  the  pains  were 
slight  and  irregular.  Labor  then  came  on  regularly,  and  within  an 
hour  afterward  she  was  delivered  naturally  of  a  still-born  infant,  of 
the  average  size,  with  the  feet  presenting.  The  urine  began  to  es- 
cape involuntarily  after  delivery.  'No  slough  was  passed,  and  she 
recovered  as  from  a  natural  labor. 

Pathological  Condition. — Laceration  had  again  taken  place  along 
the  line  of  the  previous  operation,  through  the  anterior  lip,  directly 
in  the  median  line.  The  fissure  through  the  cervix  had,  however, 
closed  nearly  to  the  uterine  canal,  leaving  a  small  fistula  in  the  base 
of  the  bladder  a  few  lines  in  front  of  the  neck. 

October  5th. — The  opening  being  so  small,  little  more  than  its 
edges  were  denuded,  and  the  raw  surfaces  were  brought  together 
with  three  sutures.  On  removing  these  an  opening  of  about  the 
same  size  was  found  near  the  cervix,  leading  forward  into  the  fistula. 
In  closing  the  fistula,  a  portion  of  the  vaginal  surface  round  the 
opening  had  been  scarified,  as  well  as  its  edges,  for  the  purpose  of 
increasing  the  breadth  of  surface  brought  together.  As  the  opera- 
tion was  so  simple  a  one,  either  care  had  not  been  taken  to  pass 
a  sufficient  number  of  sutures  to  obliterate  entirely  the  fold  form  3d 


906  DISEASES  OF  WOMEN. 

just  in  front  of  the  cervix,  on  doubling  the  surfaces  together,  or  the 
sutures  at  this  point  had  been  twisted  too  tight,  so  as  to  cut  out  from 
below  upward. 

October  30th. — For  some  distance  around  the  opening  the  tissue 
was  excavated  with  a .  pair  of  scissors,  so  that  the  surface  was  made 
to  slope  inward  to  the  opening  of  the  fistula  in  the  bladder.  The 
rest  of  the  fistulous  edge  was  then  removed  as  well  as  a  portion  of 
the  cervix,  and  the  old  cicatricial  tissue  was  gotten  rid  of  by  this 
means.  But  before  these  surfaces  could  be  brought  together,  it  was 
necessary  to  make  an  incision  on  each  side  to  reheve  the  tension 
which  would  otherwise  have  existed.  When  the  surfaces  were  folded 
together,  the  line  of  union  extended  to  such  a  distance  beyond  each 
extremity  of  the  fistula  that  the  fold  thus  formed  was  lost  in  the 
neighboring  tissue,  l^ine  sutures  were  used.  The  patient  was  dis- 
charged cured  November  18,  18G4. 

It  is  frequently  more  difficult  to  close  a  small  fistula  than  it  would 
be  where  the  large  portion  of  the  base  has  been  lost.  From  its  size 
the  temptation  is  always  great  to  remove  simply  the  edges  of  the 
opening,  instead  of  extending  the  scarification  in  the  proposed  line 
of  union  in  the  form  of  a  long  oval,  so  as  to  obviate  the  formation  of 
the  fold  at  each  end. 

This  woman  about  a  year  after  her  discharge  gave  birth,  by  a 
natural  labor,  to  her  first  living  child.  Some  eighteen  months  sub- 
sequent to  the  operation,  she  came  with  her  child  to  see  me.  I 
made  an  examination  for  the  purpose  of  ascertaining  whether  lacera- 
tion of  the  anterior  lip  had  again  occurred,  and  was  pleased  to  find 
that  the  line  of  union  was  perfect.  On  passing  a  sound  into  the 
uterine  canal,  I  was  surprised  to  find  a  suture,  which  from  its 
length,  I  was  unable  to  remove  until  it  had  been  bent  upon  itself. 
It  proved  to  be  the  one  which  had  been  passed  nearest  the  os,  and 
which  by  some  means  had  been  turned  over  backward  into  the  canal, 
with  its  end  in  the  direction  of  the  fundus.  The  portion  nearest  to 
the  fistula  had  become  buried  in  the  cervix,  with  over  half  an  inch 
of  the  other  end  free  in  the  uterine  canal.  She  had  given  birth  to 
her  child,  and  the  suture  had  remained  for  over  eighteen  months 
without  its  presence  causing  her  any  trouble.  It  has  ocurred  to  me 
that  the  remaining  of  this  suture,  which  was  passed  deep  through  the 
neck  on  a  line  with  the  vaginal  junction,  may  have  been  a  fortunate 
circumstance  in  preventing  a  recurrence  of  the  laceration. 

Vesico-Vaginal  Fistula  complicated  with  Laceration  of  Cervix;  con- 
verted into  a  Vesico-Uterine  Fistula  by  First  Operation ;  Second  Opera- 
tion completed  the  Cure.     (By  T.  A.  Emmet,  M.  D.) — Mrs.  S.,  aged 


VESICAL  AND  URETHRAL  FISTULiE.  907 

tMrtj-six,  from  Cochecton,  N.  Y.,  was  admitted  jSTovember  26, 1866. 
She  married  at  twenty-six  years  of  age,  and  had  given  birth  to  four 
children.  The  last  child  was  born  some  five  weeks  previous  to 
admission,  after  a  labor  of  forty-eight  hours.  It  was  still-born,  and 
delivered  by  "  ropes  "  as  she  stated.  She  lost  all  control  of  the  urine 
immediately  after  the  delivery. 

Pathological  Condition. — A  fi.stula  was  found  in  the  median 
line,  extending  an  inch  and  a  quarter  from  the  cervix  toward  the 
neck  of  the  bladder,  and  had  resulted  from  laceration  of  the  anterior 
lip  of  the  cervix.  The  fissure  through  the  neck  was  deeper  at  its 
terminus  in  the  uterine  canal  than  on  a  line  with  the  opening  through 
the  vaginal  surface. 

December  4th. — After  carefully  scarifying  the  sides  and  angle  of 
the  fissure  through  the  cervix,  so  as  to  include  the  entire  tract  at  the 
bottom  of  the  sulcus,  the  edges  of  the  fistula  proper  were  denuded, 
together  with  a  portion  of  the  vaginal  surface  in  advance  of  its  an- 
terior angle.  The  whole  line  was  then  secured  by  seven  sutures,  two 
of  which  were  passed  through  the  cervix  below  the  angle  of  lacera- 
tion. 

December  14th. — The  sutures  were  removed,  and  the  operation 
appeared  successful ;  but  on  the  next  day,  in  consequence  of  a  falling 
of  a  portion  of  the  ceiling  in  the  ward,  the  patient  sprang  from  her 
bed,  and  the  urine  immediately  afterward  began  to  escape.  On  ex- 
amination the  next  day,  the  urine  was  seen  escaping  from  the  os 
uteri,  while  the  cervical  and  vaginal  line  of  the  fistula  remained 
closed.     January  6,  1867,  she  returned  home  on  a  visit. 

February  19th. — Operated  again  by  splitting  open  the  cervix 
down  to  the  sinus,  and  restoring  the  parts  to  their  original  condition  ; 
otherwise,  it  would  have  been  impossible  to  have  reached  the  fistulous 
tract.  The  previous  operation  was  repeated,  and  the  only  difficalty 
in  the  case  was  experienced  in  passing  the  four  deep  sutures  through 
the  neck  so  as  to  go  below  the  bottom  of  the  fissure. 

March  4:th. — The  sutures  were  removed,  and,  although  a  portion 
of  the  line  nearest  to  the  uterine  canal  gaped  for  a  short  distance  on 
withdrawing  the  suture,  the  line  of  union  remained  perfect  below. 
The  case  was  discharged  cured  March  18,  1867. 

Laceration  of  the  Anterior  Lip  of  the  Cervix  Uteri  and  Base  of  the 
Bladder  in  the  Median  Line;  partially  closed  by  Nature,  leaving  a 
Sinus  communicating  with  the  Cervical  Canal  above  the  Vaginal  Junc- 
tion; cured  by  closing  the  Os  Uteri.  (By  T.  A.  Emmet,  M.  D.) — Mrs. 
G.,  aged  thirty-two,  a  native  of  Ireland,  was  admitted  from  Astoria, 
Long  Island,  March  8,  1863.     She  had  been  married  eleven  years. 


908  DISEASES   OF   WOMEN. 

and  had  given  birth  to  six  children  at  full  term,  all  still-born,  and 
five  had  been  delivered  bj  forceps.  Her  general  health  had  always 
been  excellent.  The  pains  of  her  sixth  and  last  labor  commenced 
on  Saturday  forenoon.  May  15,  1858.  The  membranes  (as  in  each 
previous  labor  except  the  first)  had  suddenly  ruptured  several  days 
before  the  pains  actually  came  on.  As  the  pains  were  slight,  and 
but  little  progress  was  made,  the  physician,  on  Sunday  at  5  a.  m., 
tm-ned  and  delivered  by  the  feet  a  still-born  child  of  not  more  than 
an  average  size. 

The  bladder  had  been  emptied  on  Sunday  by  means  of  a  cath- 
eter, but  the  urine  commenced  to  escape  through  the  vagina  on  the 
day  after  delivery,  and  two  weeks  afterward  several  small  sloughs 
were  passed.  Since  her  confinement,  menstruation  had  been  both 
irregular  and  scanty,  while  for  four  months  previous  to  admission  it 
had  been  totally  absent. 

Pathological  Condition. — It  was  only  after  introducing  the 
speculum  that  the  direction  by  which  the  urine  escaped  could  be 
discovered.  The  cervix  uteri  had  been  lacerated  laterally  to  the 
vaginal  junction  on  each  side,  and  the  urine  passed  entirely  from 
the  uterine  canal.  After  drawing  the  anterior  lip  forward,  a  small 
opening  into  the  uterine  canal,  on  a  hne  with  the  vaginal  junction, 
was  detected. 

A  small  probe  was  passed,  but,  after  a  most  careful  examination, 
the  opening  from  the  bladder  could  not  be  found.  From  its  situa- 
tion, an  operation  for  closing  the  fistula  was  almost  impossible,  and 
to  have  attempted  it  by  means  of  caustic  or  a  wire  cautery  would 
have  resulted  in  entire  occlusion  of  the  uterine  canal  at  the  saihe 
point. 

After  satisfying  myself  that  pregnancy  did  not  exist,  I  deter- 
mined on  the  following  procedure  :  March  22d  the  lacerated  surfaces 
were  wholly  denuded,  including  the  angle  at  the  bottom  of  the 
fissure,  limine  deep  sutures  were  passed  from  before  backward,  shut- 
ting up  the  cei'vical  canal,  and  firmly  uniting  together  the  fiaps 
formed  by  the  anterior  and  posterior  lips.  The  sutures  were  re- 
moved on  the  eighth  day,  and  the  case  was  discharged  cured  May 
20,  1863. 

Remarlis. — It  is  probable  that  in  the  first  labor  the  lateral  lacera- 
tion occurred,  and  that  this  condition  was  the  cause  of  the  prema- 
ture rapture  of  the  membranes  in  each  subsequent  labor.  In  the 
last  delivery  the  anterior  lip  was  lacerated  in  the  median  line,  and, 
extending  forward  along  the  base  of  the  bladder,  caused  a  fistula  of 
some  extent.      This  gradually  closed    on   the  vaginal   surface   by 


VESICAL  AND   URETHRAL  FISTULA.  909 

granulation  from  the  angle  nearest  the  neck  of  the  bladder,  and,  on 
extending  to  the  cervix,  the  edges  united  from  above  downward, 
leaving  a  mere  sinus  at  the  bottom  of  the  original  fissure.  Under 
such  circumstances,  as  will  be  seen  hereafter,  my  usual  mode  of 
operating  is  to  reproduce  the  original  condition,  if  a  probe  can  be 
passed  as  a  guide  through  the  sinus  in  either  direction,  and,  after 
freshening  the  course  of  the  sinus,  to  bring  the  whole  together 
again  by  deep  sutures.  In  this  case,  without  accurately  measuring 
the  diameters  of  the  pelvis  by  a  digital  examination,  I  felt  satisfied 
that  the  antero-posterior  one  was  narrowed.  With  the  history  of 
the  case,  showing  that  in  all  her  previous  labors  she  had  been  deliv- 
ered artificially  of  still-born  children,  I  considered  it  a  fortunate  cir- 
cumstance for  her  that  the  most  advisable  operation  should  have 
removed  all  risk  of  future  pregnancy.  Previous  experience  had 
already  demonstrated  that  under  such  conditions  the  menstrual  flow 
could  pass  readily  into  the  bladder,  and  be  voided  with  the  urine 
without  the  slightest  inconvenience.  Although  I  have  not  seen  this 
patient  since  her  discharge,  I  feel  satisfied  that  no  bad  result  had 
followed  the  operation,  for,  living  as  she  does  within  a  few  miles  of 
the  city,  she  would  have  returned  according  to  promise  in  case  of 
any  difiiculty. 

Fistulse,  with  Partial  Occlusion  of  the  Vagina  anterior  to  the  Open- 
ing into  the  Bladder.     (By  T.  A.  Emmet,  M.  D.) 

First  pregnancy ;  in  labor  forty-eight  hours,  and  delivery  by  forceps.  Entrance  to  the 
vagina  nearly  closed  from  contraction  of  a  circular  slough.  Outlet  opened,  the  whole 
base  of  the  bladder  was  found  to  have  been  lost,  with  the  cul-de-aac  destroyed,  and 
the  vagina  shortened  to  an  inch  and  a  half  in  depth.  The  vaginal  canal  was  opened 
to  a  depth  of  three  inches,  and  the  fistula  closed.  Shortly  after  the  sutures  had  been 
removed,  the  angle  behind  the  right  ramus  separated ;  this  was  closed  by  a  subse- 
quent operation. 

Mrs.  M.,  aged  thirty-six,  of  Jordan,  New  York,  was  admitted 
January  19,  1867.  She  married  at  nineteen,  and  two  years  after- 
ward was  delivered  by  forceps  of  a  still-born  female  child  after  a 
labor  of  forty-eight  hours.  About  the  end  of  the  first  week,  a  large 
quantity  of  urine  suddenly  gushed  from  her,  with  no  control  subse- 
quent. After  a  lapse  of  fifteen  years,  she  was  unable  to  give  a  more 
detailed  history  of  her  case. 

Pathological  Condition. — The  vaginal  outlet  was  found  so  much 
contracted  by  a  slough  behind  the  perinseum  that  the  index-finger 
could  not  be  introduced  ;  but  just  within  the  passage  was  seen  a  por- 
tion of  the  bladder-wall  prolapsed. 

January  22d. — The  index-finger  of  the  left  hand  was  introduced 


910  DISEASES   OF  WOMEN. 

into  the  rectum,  and,  as  the  band  was  pressed  up  to  the  vaginal  out- 
let, it  was  freely  snipped  at  several  points  by  scissors.  As  an  advance 
was  gained,  it  was  found  that  the  cicatricial  surface  encircled  the 
greater  part  of  the  canal,  and,  extending  along  the  lateral  walls,  in- 
vaded the  cul-de-sac.  The  whole  base  of  the  bladder  had  been  lost, 
and,  by  contraction,  the  vagina  was  shortened  to  an  inch  and  a  half, 
drawing  down  the  uterus  to  the  neck  of  the  bladder.  A  transverse 
vesico-vaginal  fistula  extended  from  one  ramus  to  the  other,  the  an- 
terior lip  of  the  cervix  forming,  to  a  great  extent,  the  posterior 
boundary  of  the  opening.  The  cicatricial  surface  was  freely  divided 
by  scissors  at  various  points,  and  the  cul-de-sac  was  opened  up,  so 
that  a  glass  plug  of  over  three  inches  was  readily  introduced. 

February  19th. — It  was  found  that,  by  the  continued  use  of  the 
plug,  the  vaginal  walls  had  become  much  softer,  and  in  a  more 
healthy  condition. 

February  22d. — Closed  the  fistula  with  fifteen  sutures.  It  was 
with  much  difiiculty  that  the  angles,  which  extended  somewhat 
upon  the  lateral  waUs  and  almost  out  of  sight  behind  the  ramus, 
could  be  properly  scarified,  or  the  sutures  introduced.  The  edges 
of  the  fistula  lay  nearly  in  contact,  and  the  line  of  scarification  on  its 
posterior  edge  was  extended  entirely  across  the  anterior  lip  of  the 
cervix,  just  in  front  of  the  os  uteri.  From  the  fact  that  so  large  a 
portion  of  the  bladder  had  been  lost,  as  much  as  possible  of  the  cer- 
vix was  intentionally  turned  into  the  bladder,  against  the  mouth  of 
the  urethra,  to  aid  mechanically  in  the  retentive  power ;  for  with  an 
accumulation  of  urine  in  the  bladder,  causing  it  to  rise  with  the 
uterus  in  the  pelvis,  the  urethra  would  necessarily  be  pressed  up 
against  the  arch  of  the  pubes. 

March  5th. — The  sutures  were  removed,  and  the  line  of  union 
was  found  perfect. 

March  15th. — The  urine  began  to  escape  in  small  quantities,  due, 
it  was  feared,  to  the  tension  of  the  bands  drawing  the  urethral  out- 
let downward  and  backward,  so  that  by  straightening  the  canal,  the 
retentive  power  became  to  some  extent  impaired.  On  examination, 
however,  this  was  found  not  to  be  the  case.  The  escape  was  due  to 
the  separation,  for  a  short  distance,  of  the  edges  forming  the  angle 
behind  the  right  ramus,  where  the  bone  was  sparingly  covered  with 
cellular  tissue. 

April  9th. — This  opening  was  closed  in  the  long  axis  of  the  va- 
gina, after  freely  dissecting  off  the  angle  of  the  fistula  from  the  face 
of  the  bone,  and  by  the  same  means,  bringing  the  parts  fully  into 
view.     Five  sutures  were  used. 


VESICAL  AND   URETHRAL  FISTUL^E.  911 

April  20th. — The  operation  was  found  successful,  but  the  patient 
was  retained  for  fear  that  some  portion  of  the  line  might  again  sep- 
arate.    She  returned  home  cured  the  last  of  May. 

Mrs.  M.  was  again  admitted  to  the  hospital,  March,  1868.  "With- 
in a  few  weeks  she  had  noticed  a  moisture,  the  quantity  of  urine 
escaping  increasing  until,  at  the  time  of  admission,  the  escape  of 
urine  was  quite  marked.  No  opening  was  at  first  found,  and  the 
escape  of  urine  was  attributed  to  the  short  urethra.  After  several 
examinations,  a  small  one  was  discovered,  not  larger  than  a  good 
sized  bristle,  near  the  end  of  the  old  line  of  union  to  the  right,  and 
at  the  seat  of  the  last  operation.  From  it  a  tense  band  of  cicatricial 
tissue  extended  on  to  the  lateral  wall,  and,  on  pressure,  rolled  under 
the  finger  like  a  string  of  catgut.  This  was  divided  and  the  fistula 
closed,  after  removing  its  edges  in  one  piece.  When  the  sutures 
were  removed,  the  union  was  apparently  perfect,  but  in  a  few  days 
the  original  condition  was  found  to  exist.  She  was  advised  to  return 
home  for  the  present,  as  her  health  had  become  very  much  impaired, 
in  consequence  of  an  accidental  attack  of  sickness.  On  readmission, 
it  is  proposed  before  attempting  to  close  the  opening  to  remove  in  a 
mass  the  cicatricial  band,  and  to  bring  together  along  its  course 
healthy  tissue  secured  by  silver  sutures.  It  will  then  be  a  simple 
matter  in  closing  the  fistula,  after  removing  a  sufl&cient  quantity 
around  its  edges  to  reach  healthy  tissue. 

Fistula  with  Stricture  of  the  Vagina.     (By  T.  A.  Emmet,  M.  D.) 

First  pregnancy  ;  five  days  in  labor  ;  artificial  delivery.  The  vagina  was  nearly  closed  at 
the  depth  of  an  inch.  After  this  contraction  had  been  divided,  it  was  found  that 
nearly  the  whole  base  of  the  bladder  had  been  lost  beyond,  together  with  the  cul-de- 
sac,  and  the  os  uteri  occluded  and  the  vagina  shortened,  with  evidence  of  previous 
pelvic  cellulitis.  Several  operations  were  performed  for  opening  the  vagina,  and  the 
last  was  followed  by  an  attack  of  pelvic  cellulitis.  The  fistula  was  closed,  but  the 
sutures  were  removed  soon  afterward,  in  consequence  of  haemorrhage.  A  second 
operation  was  abandoned  from  excessive  haemorrhage,  but  a  third  one  was  successful. 
Subsequent  pregnancy  ;  admitted  to  Bellevue  Hospital ;  vagina  found  partially 
closed,  pelvis  contracted,  and  in  labor  with  twins.  Recurrence  of  the  fistula  in  the 
old  line,  and  subsequent  contraction  of  the  vagina.  The  fistula  again  closed,  and  the 
vagina  allowed  to  contract  after  the  operation,  to  guard  against  the  recurrence  of 
pregnancy. 

Mrs.  C,  aged  thirty,  a  native  of  England,  was  admitted  from  the 
city,  February  1, 1861.  She  married  at  eighteen.  Labor  at  full  term 
with  first  child  commenced  at  11  a.  m.,  Wednesday,  March,  1860. 
After  frequent  and  severe  pains,  the  vertex  reached  the  vulva  on 
Friday,  but  made  no  further  advance  until  the  following  Monday, 
when  the   physician  effected  delivery  by  means  unknown  to  her. 


912  DISEASES  OF  WOMEN. 

The  child  was  still-born,  weighed  ten  pounds  and  a  half,  and,  when 
delivered,  the  greater  portion  was  perfectly  black,  but  whether  from 
decomposition  or  pressure  she  was  unable  to  state. 

The  bladder  was  not  emptied  from  the  commencement  of  labor 
until  after  dehverj.  The  urine  began  to  escape  involuntarily  a  week 
after  her  confinement.  A  large  single  slough  was  thrown  off  in 
three  weeks,  and  a  number  of  threads  during  the  following  month. 

Pathological  Condition. — The  vagina,  at  the  depth  of  an  inch  or 
more,  was  found  almost  entirely  closed,  by  the  contraction  of  a  thick 
cicatricial  band  encircling  the  canal.  The  passage  through  the  con- 
stricted portion,  although  large  enough  to  allow  of  the  free  escape  of 
urine,  was  too  small  to  admit  the  finger.  This  band  was  incised  at 
several  points  until  the  canal  was  perfectly  opened.  It  was  then 
found  that  nearly  the  whole  base  of  the  bladder  had  been  lost,  to- 
gether with  the  cul-de-sac.  The  cicatricial  tissue  behind  the  cervix 
was  continuous  along  the  posterior  wall  of  the  vagina  with  the  cir- 
culai'  band,  and  by  contraction,  the  edges  of  the  opening  were  drawn 
nearly  in  contact,  so  as  to  form  a  fistula  entirely  across  the  vagina. 
The  cervix  uteri  formed  a  part  of  the  upper  boundary  of  the  fistula. 
The  OS  was  occluded  by  a  superficial  slough  on  the  neck,  and  the 
body  of  the  uterus  seemed  to  be  bound  down,  far  over  to  the  left 
side,  by  adhesions. 

A  large  plug  was  introduced  into  the  vagina,  with  directions 
that,  until  the  parts  were  perfectly  healed,  it  should  only  be  removed 
during  the  administration  of  vaginal  injections.  The  tendency  to 
contraction  was  so  great  that  the  operation  had  to  be  repeated  several 
times.  After  the  last  time  (early  in  April),  the  patient  had  a  severe 
attack  of  metritis,  with  pelvic  cellulitis,  and  was  so  much  reduced 
that  she  was  sent  home  to  recruit. 

May  16th. — On  her  retm-n  the  fistula  was  closed,  as  the  parts 
were  found  in  a  comparatively  healthy  condition.  The  greatest  dif- 
ficulty in  the  operation  was  in  consequence  of  the  line  of  the  upper 
edge  of  the  opening  being  broken  by  a  portion  of  the  cervix  project- 
ing beyond  it  into  the  fistula.     Eight  sutures  were  used. 

About  two  hours  after  the  operation  hgemorrhage  suddenly  came 
on  from  the  vagina.  An  injection  of  ice-water  was  thrown  into  the 
canal,  but  without  arresting  the  bleeding.  A  solution  of  alum  was 
then  used  ;  afterward  persulph.  of  iron,  and  finally  the  vagina  was 
tamponed,  and  as  firmly  packed  as  was  deemed  possible  without 
tearing  open  the  recently  approximated  edges.  All  means  having 
failed,  and  it  being  impossible  to  see  from  what  point  the  haemor- 
rhage came,  at  midnight  the  tampon  was  taken  out,  the  sutures  re- 


VESICAL  AND   URETHRAL  FISTULA.  913 

moved,  and  the  canal  packed  firmly  with  damp  cotton  moistened 
with  a  solution  of  alum. 

June  4th. — Again  attempted  to  close  the  fistula,  but  the  hsemor- 
rhage  was  so  great  on  denuding  the  edges  with  the  knife,  that  the 
operation  had  to  be  abandoned  and  the  vagina  tamponed. 

June  24th. — The  fistula  was  successfully  closed  by  six  sutures, 
and  the  case  discharged,  cured,  July  16,  1862. 

Second  pregnancy,  twins  ;  partial  occlusion  of  the  vagina,  with  the  antero-posterior 
diameter  found  contracted  to  2|  inches.  Twenty-eight  hours  in  labor ;  delivered  by 
perforation,  the  first  child  presenting  by  the  breech,  the  second  by  the  head. 

On  the  8th  of  the  following  May,  I  was  called  on  by  Dr.  For- 
dyce  Barker,  who  was  then  on  duty  at  Beilevue  Hospital,  for  some 
history  of  the  case,  as  she  was  in  labor  at  the  time  in  that  institu- 
tion. He  stated  that  while  it  was  evident,  from  auscultation,  that 
she  was  pregnant  with  twins  yet  the  vagina  was  apparently  closed. 
After  giving  him  her  history,  I  rejnarked  that  unless  perfect  occlu- 
sion existed,  it  was  likely  that  the  cicatricial  tissue  would,  for  the 
time,  soften  down,  and  almost  entirely  disappear  during  the  prog- 
ress of  labor,  as  I  had  observed  the  same  result  in  a  similar  case. 
On  examining  her  several  hours  afterward  the  vagina  was  found  in 
nearly  a  natural  condition,  but  the  pelvis  too  much  contracted  for 
natural  delivery. 

A  consultation  was  called,  and  delivery  accomplished,  after  the 
birth  of  the  breech,  by  Dr.  Taylor  perforating  the  head  of  the  first 
child ;  and  as  the  head  of  the  other  presented  it  was  delivered  in 
the  same  manner  by  Dr.  Geo.  T.  Elliot,  Jr.  It  was  found  on 
measuring  the  pelvis,  that  the  antero-posterior  diameter  was  scarcely 
two  and  three-quarter  inches.  Immediately  after  delivery,  the  urine 
began  to  escape  by  the  vagina. 

June  8,  1863. — The  patient  w^as  readmitted  to  the  Woman's 
Hospital.  She  stated  that  menstruation  ceased  the  day  before  leav- 
ing the  hospital,  July  16,  1862,  and  that  she  became  pregnant  dur- 
ing the  following  week,  for  her  husband  left  on  a  voyage  about  that 
time  after  her  discharge,  and  consequently  she  was  ignorant  of  the 
closing  again  of  the  canal. 

The  vagina  had  contracted  nearly  to  the  condition  prior  to  de- 
livery, and,  on  incising  the  bands,  a  fistula  about  half  an  inch  in 
diameter  was  found,  nearly  in  the  old  line.  It  was  closed  by  eight 
sutures ;  they  were  removed  on  the  eighth  day ;  the  operation  had 
proved  successful,  and  she  was  discharged  from  the  hospital  a  few 
days  afterward. 

In  consequence  of  the  condition  of  the  pelvis,  and  the  likelihood 
59 


914  DISEASES  OF   WOMEN. 

of  her  death  if  she  again  became  pregnant  and  could  not  receive  the 
same  care  in  delivery,  no  effort  was  made  to  prevent  contraction  of 
the  canal,  which,  with  this  view,  had  only  been  opened  sufficiently 
to  close  the  fistula. 


URETHRAL  FISTULA. 

The  only  fistulse  of  the  urethra  that  I  have  seen  have  been  those 
made  by  myself  and  others  by  urethrotomy.  In  my  own  cases  the 
fistulse  were  made  for  the  relief  of  dilatation  of  the  middle  third  of 
the  urethra  accompanied  by  ulceration.  The  others  were  made  for 
various  purposes — one  for  the  cure  of  cystitis,  one  for  the  purpose 
of  making  a  diagnosis,  and  so  on. 

At  least  this  is  according  to  the  information  received,  taking  the 
chnical  history  given  in  the  literature  of  the  subject.  There  is 
nothing  in  the  pathology  or  method  of  treatment  of  fistula  in  this 
location  that  differs  from  that  of  vesico-vaginal  fistula.  It  is,  how- 
ever, very  much  less  troublesome,  there  being  no  incontinence  of 
urine  unless  the  fistula  involves  the  neck  of  the  bladder,  the  opera- 
tion for  c  osing  the  urethral  fistula  being  the  same  as  in  the  vaginal 
fistula. 

There  is  no  need  of  anything  more  being  said  on  this  subject. 
Cases  of  urethral  fistula  such  as  I  have  referred  to  would  add  nothing 
of  value,  hence  I  shall  give  the  histories  of  the  following  cases  which 
wiE  illustrate  urethral  fistula  caused  by  injury  inflicted  during  labor. 

Fistulae  involving  the  Urethra  from  Laceration  or  Sloughing.     (By  T. 

A.  Emmet,  M.  D.) 

first  pregnancy ;  the  head  born  at  the  end  of  seventy-four  hours ;  pains  then  ceased ; 
body  delivered  fifteen  hours  afterward  by  traction.  The  urethra  lacerated  entirely 
through  half  an  inch  from  the  meatus.  The  distal  portion  of  the  canal  so  dilated 
that  a  large  portion  of  the  mucous  membrane  protruded.  The  difficulties  of  the  opera- 
tion consisted  in  passing  the  sutures  so  as  to  bring  perfectly  into  apposition  the  two 
sections  of  the  canal  of  different  diameters.     Operation  successful. 

Mrs.  H.,  aged  eighteen,  was  admitted  from  Cold  Spring,  Long 
Island,  April  27,  1867.  She  had  been  married  two  years,  and  had 
given  birth  to  a  still-born  child. 

Labor  at  full  term  commenced  Wednesday,  January  24,  1867. 
The  pains,  however,  were  not  very  strong  or  frequent  until  the  fol- 
lowing Sunday.  At  2  p.  m.  the  head  was  born,  but  the  pains  entirely 
ceased  afterward,  and  the  body  remained  undelivered  until  Monday 
morning,  when  the  labor  was  terminated  by  traction. 

Previous  to  delivery,  the  bladder  had  not  been  emptied  for  forty- 


VESICAL   AND   URETHRAL     FISTUL^E.  915 

eight  hours ;  four  days  afterward  the  urine  began  to  dribble  away. 
It  was  not  noticed  that  any  sloughs  were  passed  from  the  vagina. 

Pathological  Condition. — Directly  across  the  urethra,  about  half 
an  inch  from  the  meatus,  a  fissure  extended  from  one  ramus  to  the 
other,  dividing  the  urethral  canal  entirely  through.  The  distal  por- 
tion of  the  urethra  was  so  dilated  that  the  index-finger  could  be 
introduced  for  some  distance  within  the  canal. 

The  mucous  membrane  anterior  to  the  neck  of  the  bladder  pro- 
truded in  a  hypertrophied  mass  as  large  as  an  almond,  resembling  a 
prolapsed  anus.  In  the  center  of  the  prolapse,  the  orifice  of  the 
canal  just  in  front  of  the  neck  of  the  bladder  remained  undilated, 
and  corresponded  in  diameter  to  the  portion  of  the  uretliral  canal 
through  the  anterior  flap. 

This  condition  was  an  unusual  complication,  as  the  prolapsed 
mass  filled  up  the  sulcus,  and,  although  it  could  easily  be  returned, 
it  was  with  great  difficulty  kept  within  the  canal  for  the  purpose  of 
scarification.  The  temptation  was  strong  to  remove  a  portion  of  it 
with  the  ecraseur,  and  wait  until  the  surface  had  healed  before  operat- 
ing ;  this  was,  however,  deemed  unadvisable  from  the  extent  of  cica- 
tricial tissue,  and  the  uncertain  amount  of  contraction  which  would 
have  resulted. 

Operation. — Ma,y  Yth. — The  whole  extent  of  the  sulcus  was  de- 
nuded around  the  edge  of  the  urethra  on  each  side  with  care,  so  as 
not  to  wound  the  mucous  membrane  of  the  canal.  Thirteen  sutures 
were  introduced. 

The  only  point  of  interest  was  in  regard  to  the  manner  of  passing 
those  nearest  the  urethra.  The  sutures  1,  2,  and  3  correspond  in  re- 
lation to  their  entrance  and  exit  on  the  vaginal  surface,  ]^os.  2  and 
3  diverge  from  the  edge  of  the  undilated  portion  of  the  urethra  to 
enter  at  a  corresponding  point  on  the  margin  of  the  dilated  portion. 

Six  sutures  on  each  side,  from  the  angles  toward  the  urethra, 
were  first  twisted ;  a  large  sound  was  then  introduced  into  the  blad- 
der to  keep  back  the  prolapsed  portion  while  securing  Nos.  2  and  3 
on  each  side  of  the  urethra.  Lastly,  iN^o.  1  was  twisted,  but,  before 
doing  so,  the  slight  prolapse  was  pushed  back  and  kept  from  pro- 
truding by  the  point  of  a  blunt  hook  passed  under  the  suture,  and 
retained  until  it  was  secured. 

On  reflection,  it  will  be  evident  that,  in  securing  the  sutures  on 
each  side  of  the  urethra,  they  niust  necessarily  approximate  to  a 
parallel  course  in  relation  to  each  other,  and  in  so  doing  the  excess 
of  tissue  would  be  rolled  thus  into  the  bladder.  While  the  dilated 
outlet  was  doubtless  folded  somewhat  on  itself  between  the  five  sut- 


916  DISEASES   OF   WOMEN. 

ures  whicli  embraced  tlie  diameter  of  tlie  urethra,  yet,  as  they  were 
passed  so  as  to  bring  the  edges  of  the  canal  at  each  point  into  exact 
apposition,  the  catheter  met  with  no  obstruction,  and  the  excess  of 
tissue  soon  retracted. 

May  17th. — The  sutures  were  removed,  and  the  operation  was 
found  successful. 

May  29th. — A  sound  was  passed  along  the  urethra,  and,  after  a 
careful  examination,  it  was  found  impossible  to  detect  the  line  of 
union,  as  not  the  slightest  irregularity  existed.  The  case  was  dis- 
charged, cured,  June  1,  1867. 

VESICO-TJTERINE  FISTULA. 

In  this  variety  of  fistula  the  opening  extends  from  the  bladder 
into  the  uterus,  usually  into  the  cervix  uteri.  It  is  generally  caused 
during  labor,  in  which  the  anterior  wall  of  the  cervix  is  torn,  and 
the  laceration  extends  into  the  posterior  wall  of  the  bladder. 

During  the  healing  which  follows  the  injury,  the  lower  portion 
of  the  wound  in  the  cervix  heals,  leaving  a  fistulous  communication 
running  from  the  bladder  into  the  canal  of  the  uterus.  The  same 
fistulous  opening  may  be  found  by  operating  for  the  purpose  of  clos- 
ing the  opening  in  the  bladder,  and  at  the  same  time  restoring  the 
laceration  of  the  cervix.  Union  is  secured  on  the  vaginal  side  of  the 
wound,  but  a  fistulous  opening,  as  described,  is  formed  by  the  failure 
to  obtain  union  in  the  deeper  part  of  the  wound. 

A  case  of  this  kind  has  already  been  quoted  from  Emmet. 

The  chief  points  of  interest  in  this  form  of  fistula  are  in  diag- 
nosis and  treatment.  The  symptoms  are  the  same  in  this  as  in  all 
fistulse  of  the  urinary  tract,  but  the  physical  signs  and  diagnosis 
dift'er.  No  physical  evidences  of  the  presence  of  the  fistula  are  ob- 
tained by  examination  with  the  speculum  except  that  the  urine  may 
be  seen  flowing  from  the  canal  of  the  uterus.  If  the  urine  does  not 
flow  at  the  time  of  the  examination,  the  bladder  should  be  filled  with 
some  colored  fluid  which  will  escape  through  the  canal  of  the  uterus, 
thus  proving  the  presence  of  the  opening. 

To  determine  its  exact  location,  and  obtain  some  idea  of  its  size, 
one  sound  should  be  passed  into  the  bladder,  and  another  into  the 
canal  of  the  uterus,  and  by  careful  manipulation  the  points  of  the 
instruments  can  be  made  to  meet.  This  will  show  where  the  open- 
ing is  situated,  and,  by  moving  the  sounds  to  and  fro,  an  idea  of  the 
size  of  the  fistula  can  be  obtained. 

Treatment. — The  method  of  closing  a  fistula  of  this  kind  is  to 


VESICAL   AND   UEETHRAL   FISTULA.  917 

divide  the  cervix  uteri  and  the  vaginal  wall  down  to  the  tract  of  the 
fistula,  and  then  pare  the  edges  thoroughly,  taking  care  to  remove 
the  scar  tissue  as  completely  as  possible.  Sutures  are  then  intro- 
duced to  close  the  entire  woand  in  the  bladder,  vagina,  and  cervix. 

I  believe  that  in  this  operation  there  is  more  likehhood  of  having 
troublesome  hsemorrhage  than  in  vesico-vaginal  fistula,  but  it  can  be 
arrested  in  the  way  already  described.  The  following  case  wiU  make 
the  whole  subject  clear  and  complete : 

A  lady  living  in  the  country  was  delivered  with  forceps  after 
having  been  in  labor  for  forty-eight  hours.  When  the  forceps 
were  used  the  cervix  was  not  fully  dilated,  and  the  operator  stated 
that  he  had  much  trouble  in  applying  the  instrument  and  deliver- 
ing. She  had  incontinence  of  urine  after  her  confinement.  One 
year  afterward  she  came  under  my  care.  There  was  then  a  scar 
running  down  about  three  quarters  of  an  inch  in  the  vagina,  from  a 
partially  healed  laceration  of  the  anterior  wall  of  the  cervix  uteri. 
The  urine  could  be  seen  flowing  from  the  cervical  canal.  A  sound 
passed  into  the  bladder  entered  the  canal  of  the  cervix  near  the  os 
internum,  and  could  be  felt  with  another  sound  in  the  canal  of  the 
cervix. 

The  operation  was  performed  by  passing  a  sound  through  the 
bladder  into  the  canal  of  the  cervix,  and  then,  by  cutting  down 
through  on  each  side  of  the  scar  tissue,  a  wedge-shaped  piece  was 
removed  which  exposed  the  tract  of  the  fistula.  The  edges  of  the 
fistula  were  then  carefully  pared,  and  the  wound  closed  with  sutures 
first  introduced  into  the  wound  of  the  bladder  and  vagina,  and  then 
into  the  cervix. 

The  catheter  was  kept  in  the  bladder  for  five  days,  and  at  the 
end  of  the  eighth  day  the  sutures  were  removed,  and  the  union  was 
found  to  be  complete. 

LOSS    OF    THE    WHOLE    BASE    OF    THE    BLADDER    AND 

URETHRA. 

It  has  been  my  good  fortune  never  to  have  seen  any  of  these 
terrible  injuries,  and  therefore  I  can  not  write  about  them  with 
advantage  to  the  readers  of  this  work.  I  will  instead  give  two 
cases  from  Dr.  Emmet's  work  on  fistula  which  will  fully  answer  all 
requirements. 

First  pregnancy;  in  labor  about  fifty-eight  hours,  and  delivered  by  forceps.  A  fistula 
existed,  involving  a  loss  of  the  whole  base  of  the  bladder,  with  the  face  of  each 
ramus  nearly  denuded  ;  the  inverted  bladder,  with  a  portion  of  intestine,  frequently 
became  strangulated  by  protruding  through  the  fistula.     Closed  by  one  operation. 


918  DISEASES   OF  WOMEN. 

Mrs.  O'D.,  aged  twenty-seven,  a  native  of  Ireland,  was  admitted 
from  Manhattanville,  N.  Y.,  April  3,  1866.  She  married  at  twenty- 
live,  and  gave  birtli  to  a  stillborn  child  five  weeks  previous  to 
admission. 

She  was  in  labor  from  Tuesday  morning  until  Thursday  night, 
when  she  was  delivered  by  forceps.  On  the  second  day  afterward 
she  noticed  the  escape  of  urine  by  the  vagina. 

PathologiGol  Condition. — A  fistula  involving  the  whole  base  of 
the  bladder,  with  but  a  few  lines  of  tissue  covering  the  inner  face  of 
each  ramus.  A  thick  band  of  cicatricial  tissue  extended  on  each 
side,  from  near  the  ramus,  along  the  sulcus,  to  the  cervix  uteri.  The 
inverted  bladder  protruded  through  the  opening  to  the  vulva.  The 
cervix  uteri,  cul-de-sac,  and  neck  of  the  bladder,  were  uninjured. 
The  vaginal  tissue  was  swollen  and  sensitive,  and  the  vulva  and 
nates  were  very  nmch  excoriated  from  the  urine  and  a  want  of 
proper  attention. 

In  two  instances  after  her  admission,  prior  to  closing  the  fistula, 
she  was  suddenly  seized  with  a  violent  colic  and  nausea,  due  to  a 
partial  strangulation  of  the  inverted  bladder  protruding  through  the 
fistula,  but  was  instantly  relieved  on  its  being  returned. 

May  15th. — The  fistula  was  closed.  Previously  to  doing  this,  the 
above-mentioned  bands  were  freely  divided  by  scissors,  and  the 
edge  of  the  fistula  dissected  ofl'  from  the  inner  face  of  the  right 
ramus.  The  edges  thus  freed  from  tension  were  then  brought 
together  in  a  line  running  obliquely  across  the  axis  of  the  vagina, 
from  the  left  ramus  to  the  right  of  the  cervix  uteri. 

When  the  edges  had  been  secured  by  eleven  sutures,  a  continu- 
ous line  was  presented  nearly  three  inches  in  length.  The  cervix 
uteri  was  drawn  down  to  within  an  inch  of  the  neck  of  the  bladder, 
but  as  the  cul-de-sac  was  in  its  integrity,  and  rather  deeper  than 
usual,  the  vagina  was  still  of  good  depth. 

May  25th.- — The  sutures  were  all  removed,  and  the  operation 
found  successful, 

June  9th. — The  case  was  discharged,  cured. 

First  pregnancy ;  in  labor  two  hundred  and  twenty-four  hours ;  delivered  by  forceps. 
Loss  of  the  whole  base  of  the  bladder,  the  cervix  uteri,  and  cul-de-sac,  with  the  in- 
verted bladder  protruding  through  the  fistula  in  the  midst  of  cicatricial  tissue.  By 
four  operations  the  opening  was  nearly  closed ;  she  was  discharged  to  recruit.  Re- 
admitted, and  cured  by  the  fifth  operation. 

Mrs.  C,  aged  twenty-seven,  a  native  of  Ireland,  was  admitted, 
from  Brooklyn,   October  17,  1864.      She  had   been   married  two 
years,  and  had  given  birth  to  one  child. 


VESICAL  AND  URETHRAL  FISTULA.  919 

Labor  commenced  at  full  term,  3  a.  m.,  Friday,  May,  1863,  by 
the  sudden  rapture  of  the  membranes.  For  the  following  week 
she  was  in  "  hard  labor,"  without  any  apparent  progress.  On  Satur- 
day, the  eighth  day,  a  physician  was  placed  in  charge,  but  the  pains 
soon  after  entirely  ceased.  On  Sunday  the  forceps  were  applied, 
and  she  was  delivered  of  a  very  large  child,  in  a  putrid  condition. 
The  placenta  was  removed  at  the  same  time. 

For  ten  days  afterward  there  was  a  free  bloody  discharge  from 
the  vagina  which  was  very  offensive.  She  was  confined  to  her  bed 
for  three  weeks  from  an  entire  loss  of  power  in  her  right  leg.  The 
urine  had  frequently  been  passed  without  difficulty  during  the  prog- 
ress of  labor.  For  a  number  of  days  after  delivery  she  had  no 
desire  to  micturate,  and  the  bladder  was  not  emptied,  but,  on  at- 
tempting to  stand,  a  very  large  quantity  of  urine  which  had  been 
accumulating  during  this  time  suddenly  gushed  from  her,  and  she 
had  no  control  afterward.  Up  to  the  time  of  admission  there  had 
been  no  return  of  menstruation. 

Pathological  Condition. — Loss  of  the  whole  base  and  destruc- 
tion of  the  cul-de-sac,  with  complete  inversion  of  the  fundus  of  the 
bladder,  protruding  from  the  fistula  through  the  labia.  From  the 
ramus  on  the  right  side,  along  the  edge  of  the  fistula,  on  the  lateral 
wall,  into  the  cul-de-sac,  a  thick  and  dense  fold  of  cicatricial  tissue 
extended,  binding  down  the  remains  of  the  cervix  uteri. 

October  25th. — This  band  was  freely  divided  in  several  places, 
the  cervix  was  freed  from  its  adhesions,  the  cul-de-sac  was  opened 
up  as  far  as  possible,  a  glass  plug  was  introduced,  and  secured  by 
a  T-bandage. 

November  22d. — Attempted  to  close  the  fistula.  The  preparatory 
operation  had  only  been  partially  successful,  as  the  patient  had  per- 
sisted in  loosening  the  bandage  whenever  she  could  do  so.  It  was 
necessary  to  perform  the  operation  entirely  on  the  knees  and  elbows, 
as,  when  on  the  side,  the  vagina  became  filled  with  the  protniding 
bladder.  After  succeeding  in  scarifying  the  edges  of  the  fistula  the 
patient  became  so  nervous  and  restless  that  I  was  forced  to  place 
her  on  the  side  and  administer  ether.  It  was  with  dilficulty  that 
she  could  be  brought  under  its  infiuence.  Before  she  was  suffi- 
ciently so,  it  became  too  dark  to  proceed  with  the  operation,  and  the 
attempt  was  abandoned. 

January  13th. — After  a  daily  driU  on  the  knees  and  elbows  by  the 
house  surgeon,  it  was  thought  that  the  operation  might  be  attempted. 
The  patient,  however,  was  as  nervous  as  before,  and,  with  much 
delay  and  difficulty,  at  the  end  of  two  hours  and  a  half,  the  scarified 


920  DISEASES   OF   WOMEN. 

edges  were  secured  by  the  sutures.  The  tension  exerted  by  the 
bands  in  the  cul-de-sac  had  not  been  entirely  relieved  by  the  pre- 
vious operation,  and,  from  the  character  of  the  tissue  forming  a  por- 
tion of  the  line  perfect  union  throughout  was  not  to  be  anticij)ated. 

January  21st. — Eight  sutures  were  removed ;  the  other  two  had 
cut  out.  The  parts  had  united  well,  except  toward  the  left,  at  the 
extremity  of  the  fistula,  against  the  ramus ;  at  this  point  the  edges 
were  thin,  tense,  and  in  the  midst  of  cicatricial  tissue. 

February  14th. — Second  operation.  The  opening  was  again  closed 
by  ten  sutures.  The  line  of  union  was  along  the  sulcus,  at  a  right 
angle  to  the  previous  one,  and  parallel  to  the  course  of  the  bands, 
so  that  no  direct  tension  could  be  exerted  by  them.  A  portion  of 
the  base  was  brought  up  in  a  fold  against  the  lateral  wall,  forming  a 
long  pouch  in  the  axis  of  the  vagina,  at  the  bottom  of  which  the 
opening  into  the  bladder  was  left.  By  this  procedure  the  tension 
was  lessened,  as  the  lateral  wall  was  more  yielding  at  a  distance 
from  the  sulcus,  and  healthier  tissue  was  brought  in  apposition.  At 
the  same  time,  the  scarified  surfaces  being  at  a  greater  distance  from 
the  bone,  more  room  was  gained  to  turn  the  needles  while  intro- 
dacing  them.  The  operation  was  a  very  tedious  one,  from  the 
patient  being  almost  ungovernable. 

February  23d. — The  sutures  were  removed.  Three  were  found 
loose  in  the  vagina,  with  as  many  small  openings. 

April  12th. — Again  operated.  The  execution  was  more  difficult 
than  before,  as,  by  contraction  of  the  cicatricial  tissue,  a  fold  had 
been  formed  along  the  axis  of  the  vagina,  just  in  fi-ont  of  the  open- 
ings, so  as  to  hide  them  from  view.  The  previous  operation  was 
repeated,  after  cutting  open  with  scissors  the  partially  closed  line, 
and  in  such  a  manner  as  to  unite  these  three  openings  into  one. 
The  scarified  surface  was  extended  beyond  each  extremity  of  the 
opening.  Eleven  sutures  were  used ;  they  were  removed  April 
20th.     The  line  had  united  at  but  a  single  point. 

May  23d. — Fourth  operation..  The  vaginal  surface  around  the 
fistula  was  scarified  with  a  corresponding  portion  on  the  side  of  the 
fold  nearest  the  opening.  The  fold  was  then  doubled  over  the 
fistula,  and  secured  by  ten  sutures.  The  opening  was  so  close  to  the 
mnscle  that  several  of  the  sutures  must  have  included  portions  of 
its  fibres,  and  with  any  movement  of  the  leg  on  that  side,  the  strain 
would  have  been  so  great  that  it  was  feared  they  would  be  torn  out. 
As  a  precaution,  the  patient's  legs  were  tied,  and  a  support  was  put 
Tinder  her  knees  while  flexed,  so  as  to  relax  the  muscles  as  much  as 
possible. 


•    VESICAL  AND   UKETHRAL  FISTULA.  921 

June  2d.— The  sutures  were  removed.  The  operation  had  proved 
a  failure. 

June  6th. — The  patient  was  discharged  to  recruit  her  health 
during  the  summer,  and  to  retura  in  the  autumn. 

She  was  readmitted,  and  operated  on,  October  17,  1866.  The 
opening  had  not  enlarged,  and  her  condition  was  favorable  in  every 
respect.  The  last  operation  was  repeated,  and  eleven  sutures  were 
employed  ;  they  were  removed  October  31st.  The  operation  was 
entirely  successful,  and  the  patient  was  discharged,  cured,  ITovember 
14th. 

Loss  of  base  of  the  bladder,  urethra,  and  cervix  uteri.  Recovei-y  after  many  operations. 
The  outlet  of  the  vagina  nearly  closed  by  a  circular  slough.  Loss  of  nearly  the  whole 
urethra,  the  subpubic  tissue,  and  that  posterior  to  the  bone  for  half  an  inch.  The 
whole  base  of  the  bladder,  the  neck  of  the  uterus,  and  the  cul-de-sac  were  destroyed 
with  the  vaginal  canal  shortened  to  an  inch  and  a  half  in  depth.  During  three 
years,  and  after  some  twenty  operations,  a  new  urethra  was  formed  by  aid  of  plastic 
surgery,  the  fistula  closed,  and  the  vagina  opened  to  three  inches  in  depth.  She  was 
discharged  with  perfect  retentive  power,  but  obliged  to  use  the  catheter.  After  sev- 
eral attacks  of  cystitis,  at  the  end  of  eighteen  months,  a  portion  of  the  line  was 
opened  for  the  removal  of  calculi,  and  not  again  closed. 

Mrs.  McD.,  aged  twenty,  from  Port  Berwell,  Canada  was  ad- 
mitted, September  26,  1862.  She  had  given  birth  to  one  child, 
but  the  recorded  history  of  her  case  does  not  state  the  time  previous 
to  admission. 

Regular  labor  at  full  term  commenced  early  on  Saturday  morn- 
ing with  frequent  and  severe  pains.  During  the  afternoon  a  physi- 
cian took  charge  of  her  case,  who,  at  his  first  examination,  inten- 
tionally ruptured  the  membranes,  as  she  stated,  and  afterward  gave 
ergot  several  times  "  to  hurry  up  the  pains."  Before  dark  the  head 
was  born,  but  no  effort  was  made  to  deliver  the  body  until  Sunday 
morning,  when  another  physician  was  placed  in  charge.  She  was 
at  once  delivered,  but  having  become  much  swollen  in  the  mean- 
time, quite  an  amount  of  force  had  to  be  exerted  in  accomplishing 
it.  The  child  was  dead  at  the  time  of  its  birth,  and  weighed  eleven 
and  a  half  pounds. 

The  urine  was  retained  some  eighty-four  hours,  from  Friday 
night  until  the  following  Tuesday,  when  a  catheter  was  introduced, 
and  regularly  afterward  for  a  week,  at  which  time  the  urine  began 
to  escape  from  the  vagina.  For  three  weeks,  portions  of  sloughs 
were  daily  thrown  off. 

Pathological  Condition. — The  mouth  of  the  vagina  was  much 
narrowed  by  a  tense  circular  band,  the  result  of  a  slough,  which  had 
destroyed  the  whole  course  of  the  uretlira,  with  the  exception  of  a 


922  DISEASES  OF   WOMEK 

line  or  two  at  tlie  meatus.  Through  the  constricted  vaginal  outlet, 
the  fundus  and  posterior  wall  of  the  bladder  protruded  in  a  partially 
strangulated  condition.  The  vagina  was  narrowed  throughout,  and 
but  an  inch  and  a  half  in  depth.  The  cul-de-sac  had  been  destroyed 
with  the  entire  cervix  uteri,  as  well  as  the  whole  base  of  the  bladder 
from  one  ramus  to  the  other.  Behind  the  pubis  a  slough  had  ex- 
tended up  about  half  an  inch,  leaving  but  little  covering  to  the  bone 
other  than  its  periosteum.  From  this  point  forward,  to  the  rem- 
nant of  the  urethra,  there  remained  but  a  portion  of  the  subpubic 
ligament  and  a  little  cellular  tissue. 

Her  genera]  health  was  good,  but  she  was  short  in  stature  and 
exceedingly  corpulent.  Altogether  her  case  was  a  most  impromising 
one. 

October  7th. — Free  incisions  were  made  through  the  band  around 
the  vaginal  outlet,  and  a  plug,  as  large  in  diameter  as  could  be  borne, 
was  introduced. 

October  26th. — A  false  passage  was  made  with  a  trocar  through 
the  soft  parts,  to  serve  as  a  part  of  the  tract  for  a  new  urethra.  A 
section  of  lead  tubing  was  introduced  with  the  two  ends  bent  to- 
gether, and  left  in  the  passage  until  the  sixth  day,  when  the  canal 
seemed  perfectly  healed. 

IsTovember  8th. — Made  free  incisions  through  the  mass  of  cica- 
tricial tissue,  "filling  the  cuZ-de-sac,  and  inserted  a  plug  into  the  canal 
of  sufficient  length  to  keep  the  parts  on  the  stretch  by  aid  of  a  T- 
bandage. 

JSTovember  21st. — Found  that  the  false  passage  for  the  urethra  had 
gradually  closed ;  a  larger  puncture  was  made,  and  it  was  directed 
that  a  catheter-tube  should  be  retained  for  a  longer  time,  until  the 
canal  had  perfectly  healed.  .  .  . 

A  false  passage  had  been  made  above  through  healthy  tissue  for 
a  portion  of  the  urethra,  with  the  intention  of  continuing  this  for- 
ward under  the  arch  of  the  pubis ;  but  to  do  so  it  was  necessary  to 
fill  the  sulcus  or  excavation  lost  by  sloughing.  The  false  passage, 
however,  gradually  closed,  and  the  attempt  was  abandoned  to  keep 
it  open. 

To  accomplish  the  object,  the  opposite  sides  of  the  triangle  form- 
ing the  sulcus  were  scarified,  leaving  only  a  narrow  strip  at  the  bot- 
tom, between  the  denuded  surfaces,  to  serve  as  the  urethral  tract. 
Two  diverging  incisions  from  above  downward  were  then  made 
through  the  cellular  tissue  behind  the  pubis,  parallel  to  the  edges 
of  the  sulcus.  The  denuded  sides  of  the  sulcus  were  then  shd  to- 
gether in  the  median  line,  and  secured  by  seven  sutures,  leaving  an 


VESICAL  AND  URETHRAL  FISTULA.  923 

undenuded  tract  behind  the  two  flaps  for  the  urethra.  It  was  re- 
markable that  the  haemorrhage  was  comparatively  slight.  After  the 
mucous  membrane  had  been  divided  in  line  by  scissors,  any  portion 
of  the  flap  in  the  loose  cellular  tissue  behind  the  pubis,  when  pot  on 
the  stretch  by  a  tenaculum,  was  easily  lacerated  in  line,  as  directed  hy 
the  tension,  with  but  slight  aid  from  the  handle  of  a  scalpel.  The 
operation  had  to  be  performed  entirely  on  the  knees  and  elbows, 
and  required  about  two  hours  for  its  execution.  The  line  brought 
together,  an  inch  in  length,  was  composed  of  the  tissue  forming 
the  anterior  wall  of  the  bladder,  and  extended  entirely  within  the 
cavity. 

The  operation  was  performed  December  12th  ;  a  week  afterward 
the  sutures  were  removed,  and  the  operation  proved  a  success. 

December  29th. — Extended  the  incisions  into  the  cul-de-sac,  so  as 
to  increase  the  depth  of  the  vagina  over  half  an  inch,  and  freed,  at 
the  same  tioae,  the  remains  of  the  cervix  uteri  from  adhesions  on 
each  side ;  the  use  of  the  plug  was  continued. 

January  9th.^ — -Endeavored  to  place  her  under  the  influence  of 
ether  to  close  the  fistula,  but,  after  an  attempt  of  two  hours,  and 
using  more  than  a  pound  of  ether,  it  was  abandoned,  finding  it  im- 
possible to  get  her  sufficiently  relaxed. 

January  16, 1863. — Administered  chloroform,  but  with  no  better 
success ;  there  was  no  relaxation  of  the  muscles,  and,  although  at 
times  apparently  fully  under  the  influence  of  the  anaesthetic,  yet,  as 
soon  as  any  attempt  was  made  to  introduce  the  speculum,  she  would 
immediately  straighten  out  of  position. 

February  1st. — Without  an  anaesthetic,  after  two  hours,  with  much 
delay  from  the  great  nervousness  of  the  patient,  the  uterus  was  retro- 
verted,  drawn  forward,  and  the  remains  of  the  anterior  lip  of  the 
cervix  united  ...  to  compose  the  new  urethral  canal,  recently  formed 
behind  the  pubes.  The  line  of  union  was  crescentric,  with  its  cornua 
extending  an  inch  or  more  posterior  to  the  cervix  on  each  side. 

Thirteen  sutures  were  used,  but  a  gap  was  left  in  the  line  in  front 
of  the  uterus  for  the  urine  to  escape,  while  the  urethra  was  being 
afterward  extended.  The  sutures  were  removed  on  the  ninth  day  ; 
the  union  was  perfect  nearly  throughout,  and  the  operation  was  suc- 
cessful, so  far  as  it  was  expected  to  be,  in  retaining  the  uterus  in  its 
new  position,  so  that  the  neighboring  parts  could  become  properly 
molded  for  after  use. 

May  17th. — After  a  large  anodyne,  to  aid  the  action  of  the  an- 
aesthetic, ether  was  again  administered.  By  tying  the  patient  in 
position  on  the  left  side  with  sheets,  it  was  hoped  that  the  difiiculty 


924  DISEASES   OF  WOMEN. 

might  be  overcome.  She  was  brought  fully  under  the  influence  of 
the  ausesthetic,  yet  so  great  was  the  reflex  irritation  on  introducing 
the  speculum,  that  it  was  unpossible,  with  the  full  strength  of  sev- 
eral gentlemen  j)i'esent,  to  keep  her  in  position,  even  when  securely 
tied. 

She  was  at  length  allowed  to  become  conscious,  and  I  proceeded 
to  operate  with  great  difficulty,  as  she  was  unable  to  bear  a  sufficient 
amount  of  traction  on  the  perinagum  from  the  speculum  to  freely 
open  the  vagina. 

The  operation  was  to  close  a  portion  of  the  line  united  February 
1st,  which  was  situated  behind  and  to  the  right  side  of  the  cervix 
uteri,  where,  being  in  the  midst  of  cicatricial  tissue,  it  had  separated 
in  a  number  of  small  openings. 

After  dividing  to  some  extent  the  tissues  beyond  in  the  cul-de- 
sac,  so  as  to  reheve  all  tension,  the  openings  were  extended  into  one 
by  a  cut  of  the  scissors.  The  edges  were  then  carefully  denuded  so 
as  to  remove  each  point  where  union  had  not  taken  place.  The 
sides  of  the  opening  were  secured  by  fourteen  sutures  and  the  opera- 
tion completed  at  the  end  of  three  hours  and  a  half. 

On  removing  the  sutures  it  was  found  that  the  urine  was  escap- 
ing in  small  quantities  at  several  points,  but,  by  continuing  the  use 
of  the  catheter  for  a  few  days  longer,  the  openings  closed  by  con- 
traction. 

June  26th. — The  remains  of  the  old  urethra  at  the  meatus  re- 
moved preparatory  to  an  operation  for  extending  forward  the  new 
canal.  In  principle  the  procedure  was  the  same  as  that  adopted  at 
the  previous  operation  behind  the  pubes.  Two  parallel  lines  of 
freshened  surface  were  made,  .  .  .  forward  under  the  arch  of  the 
pubes,  a  little  beyond  the  termination  of  the  old  urethra,  leaving  an 
unscarified  strip  between  them,  about  half  an  inch  in  width,  to 
serve  as  the  tract  of  the  new  canal.  Outside  and  parallel  to  each 
denuded  line  a  free  incision  was  made  inward  and  somewhat  beneath 
the  raw  surfaces  in  the  direction  of  the  symphysis  pubis.  These 
incisions  were  extended  beneath  to  free  the  soft  parts  sufficiently 
that  the  freshened  surfaces  on  the  flaps  could  be  rolled  over  in 
contact.  The  surfaces  were  secured  by  seven  sutures  over  a  catheter, 
passed  in  the  course  of  the  new  urethra,  and  held  by  an  assistant 
until  all  had  been  twisted. 

She  was  then  placed  in  bed  on  her  back,  with  her  knees  flexed 
and  tied  together.  The  catheter  was  retained  in  the  canal  and  sup- 
ported in  a  sling  of  sticking-plaster  from  above  the  pubis  so  that  the 
line  of  union  in  its  integrity  might  not  be  impaired  by  the  weight. 


VESICAL  AND   URETHRAL  FISTULtE.  925 

When  the  sutures  were  removed,  it  was  observed  that  one  at 
each  end  had  nearly  cut  out  from  being  twisted  too  tight — a  difficult 
matter  to  avoid,  as  the  soft  parts  at  each  end  of  the  line  were  so 
yielding  as  to  render  the  point  uncertain  at  which  the  suture  had 
been  properly  secured. 

The  result  was  that  quite  an  opening  was  left,  where  the  two 
sections  had  been  joined,  but  forward  for  an  inch  the  canal  was 
perfect. 

July  20th. — She  returned  home  for  the  summer,  and  was  read- 
mitted to  the  hospital  October  25,  1863. 

A  few  days  afterward  she  had  an  operation  for  increasing  the 
depth  of  the  vagina. 

December  2d. — Closed  the  opening  in  the  urethra  by  six  sutures 
in  a  line  transverse  to  the  axis  of  the  vagina.  The  sutures  were  re- 
moved on  the  sixth  day,  and  the  operation  was  found  to  have  been 
successful. 

She  was  now  in  a  condition  to  be  discharged  cured,  as  she  re- 
mained perfectly  dry  ;  but,  from  the  character  of  the  tissue  through- 
out the  vagina,  I  determined  to  keep  her  under  observation  for  a 
month  or  two  longer  before  returning  home. 

January  12,  1864. — The  urine  began  to  escape,  it  was  found, 
from  a  number  of  minute  openings  about  the  center  of  the  line  of 
the  urethra.  They  were  all  opened  into  one  by  the  scissors,  and  the 
edges,  which  were  now  very  thin,  were  freshened  with  as  little  loss 
of  tissue  as  possible.  Twelve  sutures  were  introduced,  as  it  was 
necessary,  in  consequence  of  the  thin  edges,  to  extend  the  denuded 
surface  on  the  vagina  from  the  meatus  nearly  to  the  cervix  uteri  so  as 
to  bring  together  two  folds  up  over  the  line.  The  tissues  were  so  fria- 
ble and  soft  that  it  was  impossible  to  judge  as  to  the  proper  twisting 
point  for  the  sutures.  The  knees  were  tied  together  as  before,  a 
precaution  still  more  necessary,  as  the  tension  was  now  so  great  that 
they  could  not  be  separated  to  any  extent  without  making  traction 
on  the  sutures. 

On  the  eighth  day  the  sutures  were  carefully  removed,  but  with 
difficulty,  as  the  parts  had  become  much  swollen  and  inflamed. 

February  22d. — Closed  a  small  opening  which  had  again  formed 
in  the  urethra.  Its  edges  were  too  thin  to  be  brought  together  alone, 
therefore  the  vaginal  surface  was  denuded  at  some  distance  around, 
while,  as  in  the  first  operation,  two  parallel  incisions  were  made  out- 
side, and  the  flaps  doubled  over  together  along  the  old  line. 

Seven  sutures  were  used.  They  were  removed  on  the  tenth  day, 
and  the  operation  was  apparently  successful. 


926  DISEASES  OF  WOMEN". 

Marcli  ISth. — Operated  to  close  an  opening,  smaller,  but  at  the 
same  point. 

She  had  kept  perfectly  dry  some  time  after  the  last  operation, 
but  when  the  catheter  had  been  discarded  she  found  that  the  urine 
would  accumulate  in  large  quantities,  without  any  power  or  desire 
to  empty  the  bladder.  The  catheter  was  resorted  to  by  her  for  re- 
lief, but  I  was  satisfied  that  it  was  not  used  at  proper  intervals,  and 
to  the  traction  thus  exerted  the  opening  was  due. 

April  19th. — The  urine  began  to  escape  from  a  large  opening 
which  suddenly  formed  on  the  right  side  behind  the  cervix,  at  the 
extreme  angle  of  the  line  made  where  the  uterus  was  drawn  forward, 
to  be  united  under  the  arch  of  the  pubis.  Through  this  opening  a 
portion  of  the  fundus  of  the  bladder  now  protruded.  It  was  closed 
by  nine  sutures  and  with  but  little  hope  of  success,  as  its  edges  were 
entirely  cicatricial.  The  operation,  however,  proved  perfectly  suc- 
cessful. 

May  20th. — Closed  the  opening  in  the  urethra,  the  only  one  now- 
remaining,  using  eleven  sutures. 

This  023eration  was  also  successful ;  but,  when  the  sutures  were 
being  removed,  a  small  opening  was  detected  at  the  seat  of  the  pre- 
vious operation,  to  the  left  of  the  neck  of  the  uterus.  The  catheter 
was,  however,  continued  in  use  for  some  ten  days  longer,  when  the 
opening  was  found  to  have  closed  by  contraction. 

July  4,  1864. — She  returned  home,  keeping  perfectly  dry,  but 
without  any  voluntary  power  of  emptying  the  bladder. 

Her  condition  was  as  follows :  The  vagina  had  been  opened  to 
a  depth  of  over  three  inches ;  the  fistula  had  been  closed,  and  an 
entire  new  urethra  formed,  with  perfect  retentive  power,  but  ina- 
bility to  empty  the  bladder,  except  by  means  of  a  catheter. 

February  15,  1865. — She  was  readmitted,  giving  the  following 
history :  Until  January,  she  had  remained  perfectly  well,  when  she 
began  to  suffer  from  tenesmus  and  irritability  of  the  bladder,  requir- 
ing the  frequent  introduction  of  the  catheter.  The  urine  became 
thick  and  offensive,  with  such  an  accumulation  of  mucus,  that  the 
catheter  would  become  obstructed  almost  as  soon  as  it  was  introduced. 
In  a  short  time  afterward  the  urine  began  to  escape  by  the  vagina 
with  great  relief  to  her  sufferings. 

On  examination  it  was  found  that  an  opening  existed  in  front  of 
the  uterus,  at  the  junction  of  the  line  with  the  urethra,  and  through 
which  a  No,  12  bougie  could  be  readily  passed. 

The  cystitis  was  treated  by  frequently  washing  out  the  bladder 
with  tepid,  water,  and  she  improved  rapidly. 


VESICAL  AND   URETHEAL  FISTULA.  927 

She  had  never  menstruated  since  her  pregnancy,  nor  was  it  antici- 
pated that  she  would  again,  from  the  fact  that  atrophy  of  the  uterus 
had  taken  place,  as  a  result  of  the  inflammation  by  which  the  entire 
cervix  had  been  lost,  leaving  the  organ  barely  an  inch  and  a  half  in 
depth.  I  have  already  refei-red  to  this  fact,  and  have  observed  the 
result  frequently.  The  earliest  instance  which  passed  under  my 
notice  was  a  case,  where,  at  the  age  of  thirty-six,  menstruation  had 
not  returned  after  an  interval  of  fourteen  years  from  the  reception 
of  the  injury,  and  yet  the  woman  had  remained  in  good  health. 

In  this  case,  however,  from  the  beginning  of  the  cystitis,  there 
had  been  a  regular  menstrual  nisus,  but  with  no  flow.  It  was  sug- 
gestive, and,  in  connection  with  the  treatment  for  the  cystitis,  a 
small  sponge  tent  was  introduced  into  the  uterine  canal  every  other 
day,  and  removed  at  the  end  of  twelve  hours.  After  these  had  been 
used  for  two  or  three  weeks,  the  discharge  following  their  removal 
became  more  profuse,  and  with  great  relief  to  the  pain  in  the  back 
and  to  the  constant  feeling  of  weight  about  the  organ. 

By  the  beginning  of  April,  the  uterus  had  increased  so  much  in 
size  that  the  canal  was  two  inches  deep,  and,  with  an  allowance  for 
the  lost  cervix,  the  organ  had  now  become  nearly  of  normal  size. 
At  this  time  after  removing  a  tent,  the  show  was  more  than  usual ; 
it  continued  and  lasted  for  several  days.  Without  speculating  as  to 
cause  and  effect,  it  is  an  interesting  feature  in  the  history  of  her 
case,  that  all  symptoms  of  irritation  of  the  bladder  ceased  as  soon  as 
the  menstrual  flow  became  established,  and  in  fact,  lessened  from 
the  first  discharge  following  the  use  of  the  tents. 

April  7th. — With  seven  sutures,  the  opening  into  the  urethra  was 
closed,  by  bringing  together  two  folds  of  vaginal  tissue  over  it,  in  a 
line  transverse  to  the  axis  of  the  vagina.  On  the  eighth  day  the 
sutures  were  removed,  and  she  returned  home  in  excellent  condition, 
May  9,  1865. 

On  the  14th  of  February,  1866,  she  was  again  admitted  to  the 
hospital,  and  presented  the  following  statement :  For  six  months 
after  her  return,  she  remained  perfectly  well,  and  had  five  menstrual 
periods.  Gradually,  however,  after  this  time,  irritability  of  the 
bladder  came  on  with  the  cold  weather,  and  she  then  suffered  from 
the  same  train  of  symptoms  as  before. 

Her  difficulty  increased,  until  January,  when  suddenly  the  urine 
again  escaped  by  the  vagina,  but  without  affording  the  same  relief 
as  before. 

An  opening  from  the  urethra  into  the  vagina  was  found,  situated 
in  front  of  the  cervix  uteri  as  at  first,  with  another  opening  from 


928  DISEASES   OF   WOMEN". 

the  urethra  into  the  bladder.  On  introducing  a  sound  a  mass  of 
calculi  was  detected  in  the  pouch,  or  most  depending  portion  of  the 
bladder,  formed  by  the  anterior  wall  of  the  retroverted  uterus.  The 
opening  was  enlarged,  and  nine  phosphatic  calculi  were  removed ;  the 
whole  number  in  bulk  were  sufficient  to  fill  an  ordinary  wine-glass. 

The  cystitis  was  treated  as  before,  but  with  the  injections  acidu- 
lated with  dilute  nitric  acid.  She  was  soon  entirely  relieved,  and 
returned  home,  April  17,  1866. 

The  fistulous  opening  was  not  closed,  and  it  was  advised  that  it 
should  remain  open  for  a  year,  thus  enabling  the  bladder,  by  rest,  to 
regain  its  tone.  At  the  end  of  that  time  she  was  to  return  for  an 
operation,  as  I  contemplated  changing  the  course  of  the  urethra. 
She  never  returned,  however,  and  I  am  ignorant  of  her  present 
condition. 

In  connection  with  the  following  case,  the  subject  will  be  illus- 
trated of  establishing  a  most  important  point,  resulting  from  the 
practical  teaching  gained  by  this  failure.  After  taking  into  consid- 
eration how  much  was  accomplished  in  this  case,  it  must  be  regarded 
as  a  triumph  for  plastic  surgery,  for  indeed  it  would  be  difficult  to 
conceive  that  another  could  be  presented  with  a  greater  destruction 
of  tissue,  except  with  the  loss,  in  addition,  of  the  recto-vaginal 
septum. 

I  am  not  aware  that  the  attempt  has  ever  been  made,  or  been 
before  successful,  toward  the  formation  of  an  entire  urethral  tract, 
as  in  tliis  case,  where  the  tissues  were  all  lost  under  the  arch  of  the 
pubis ;  or  that  a  similar  operation  was  ever  performed  within  the 
bladder  itself. 

As  a  surgical  procedure  it  was  a  success,  for  the  retentive  power 
existed  six  months  at  a  time.  The  formation  of  calculi  resulted 
from  the  presence  of  stale  urine  in  the  bladder,  because  it  could 
never  be  emptied  below  the  point  at  which  the  false  passage  entered 
it ;  and  yet  the  result  might  have  been  different  with  the  exercise 
of  proper  care  on  the  part  of  the  patient.  Tlie  difficulty  in  having 
to  trust  so  much  to  the  after-care  of  the  patient,  I  hope,  has  now 
been  obviated,  for  relief  has  been  gained  by  the  method  in  other 
cases  since,  and  I  hope  may  yet  be  put  in  practice  in  the  one  under 
consideration.  The  above  cases  of  extraordinary  injuries  to  the 
urethra  and  bladder,  taken  from  the  work  of  T.  A.  Einmet,  M.  D., 
are  a  remarkable  monument  to  that  consummate  surgeon's  skill  and 
perseverance. 


CHAPTEE   LI. 

GYNECOLOGY   AS    RELATED   TO    INSANITY   IN   WOMEN. 

The  relations  whicli  exist  between  the  sexual  organs  of  women 
and  diseases  of  the  brain  and  nervons  system,  had  occupied  some  of 
my  time  and  attention  in  the  past,  but  my  opportunities  for  obseiwa- 
tion  were  limited,  until  Dr.  J.  C.  Shaw,  the  Medical  Director  of  the 
King's  County  Insane  Asylum  at  Flatbush,  invited  me  to  take  charge 
of  the  gynecological  practice  in  that  institution,  counting  among  its 
inmates  about  four  hundred  female  patients.  This  gave  me  extended 
facilities  for  studying  this  special  department  of  medicine  as  it  pre- 
sents itself  among  the  insane. 

Upon  entering  this  field  of  observation,  I  was  confronted  with 
an  entirely  new  phase  of  practice,  in  which  the  ordinary  methods  of 
investigation  were  of  little  value.  No  correct  histories  could  be 
obtained  from  the  patients  themselves,  and  the  records  kept  by  the 
physicians  in  charge,  though  full  and  correct  in  all  that  pertained  to 
the  mental  conditions,  afforded  but  little  information  of  value  to  the 
gynecologist. 

The  routine  business  common  to  all  these  institutions,  made  it  im- 
perative to  acquire  the  art  of  investigation  in  this  department.  In- 
formation was  sought  in  records,  regarding  gynecological  practice 
among  the  insane,  without  avail,  and  so  I  was  obliged  to  devise  a 
method  of  examining  patients. 

The  system  of  investigation  adopted,  and  the  phenomena  ob- 
served, together  with  the  deductions  drawn  therefrom,  form  the 
subject  matter  of  this  chapter. 

It  should  be  clearly  understood  that  the  subject  to  be  discussed 
is  limited  simply  to  the  relation  which  gynecology  bears  to  insanity. 

Eegarding  the  etiological  relations  of  diseases  of  the  brain  and 

sexual  organs,  little  need  be  said  at  this  date.     I  take  it  for  granted 

that  all  will  agree  that  insanity  is  often  caused  by  diseases  of  the 

procreative  organs,  and  on  the  other  hand,  that  mental  derangement 

60 


930  DISEASES  OF    WOMEN. 

frequently  disturbs  the  functions  of  other  organs  of  the  bodj,  and 
modifies  diseased  action  in  them.  Either  may  be  primary  and  caus- 
ative, or  secondary  and  resultant.  In  the  literature  of  the  past,  we 
find  the  gynecologist  pushing  his  claims  so  far  as  to  lead  a  junior  in 
medicine  to  believe  that  if  the  sexual  organs  of  women  were  pre- 
served in  health,  insanity  would  seldom  occur  among  them.  While 
the  psychologist,  or  alienist,  holds  that  women  will  lose  their  reason 
and  regain  it,  without  much  help  or  hinderance  from  their  repro- 
ductive organs.  The  ablest  and  best  men  on  both  sides  take  the 
human  organization  as  a  whole,  and  give  to  each  portion  its  legiti- 
mate share  of  credit  for  good  and  evil.  On  this  branch  of  medicine 
the  boundary-lines  which  divide  the  gynecologist  and  psychologist 
often  touch  and  cross  each  other,  and  it  is  necessary  that  we  should 
know  where  they  touch,  and  where  they  diverge.  To  know  this 
will  insure  a  cordial  agreement  as  to  when  the  two  specialists  shall 
act  separately,  and  the  conditions  which  require  them  to  labor  to- 
gether for  the  benefit  of  those  who  suffer  in  body  and  mind. 

From  my  investigations,  I  have  been  led  to  the  belief  that  up  to 
the  present  time  the  effect  of  disease  of  the  sexual  organs  in  women, 
in  causing  and  keeping  up  insanity,  has  been  more  correctly  studied 
than  the  influence  which  insanity  exercises  upon  the  sexual  organs. 
This  opinion  may  have  been  formed  from  the  fact  that  my  observa- 
tions have  been  made  especially  from  the  standpoint  of  the  gyne- 
cologist, and  therefore  the  other  side  of  the  question  has  not  been  so 
clearly  seen.  But  the  reasons  for  holding  this  belief  are,  that  the 
one  line  of  investigation  is  easier  than  the  other,  and  our  literature 
shows  that  most  investigators  have  chosen  the  sexual  organs  as  the 
starting-point  of  their  inquiries.  The  gynecologist  has  the  advan- 
tage of  knowing  when  his  patients  have  uterine  or  ovarian  disease, 
and  if  insanity  follows  in  any  of  his  cases,  he  may  be  able  to  estimate 
the  influence  of  the  primary  disease  in  causing  the  mental  disorder. 
On  the  other  hand,  the  psychologist  may  have  a  number  of  insane 
patients  who  suffer  from  uterine  and  ovarian  diseases  which  may 
escape  his  notice.  This  may  readily  occur  even  among  the  cases  of 
insanity  caused  by  diseases  of  the  sexual  organs.  Derangement  of  the 
mind  often  obscures  all  the  symptoms  of  bodily  disease,  and  therefore 
the  medical  attendant  is  liable  to  be  misled.  One  is  not  apt  to  over- 
look insanity  in  patients  known  to  have  disease  of  the  sexual  organs, 
and  hence  the  advantage  that  the  gynecologist  has  in  studying  the 
relations  of  these  two  forms  of  morbid  action.  For  reasons  such  as 
these,  one  should  not  find  fault  with  psychologists  for  not  having 
done  more  to  develop  this  branch  of  medical  science,  but  rather  re- 


GYNECOLOGY  AS  RELATED  TO  INSANITY   IN   WOMEN.   931 

mind  gynecologists  that  they  have  done  so  little,  considering  their 
opportunities. 

At  this  point,  attention  may  be  directed  to  the  way  in  which 
diseases  of  the  sexual  organs  cause  insanity.  We  have  long  recog- 
nized the  cause  and  the  effect,  but  the  mode  of  action  of  the  one  in 
producing  the  other  may  be  admitted,  in  many  cases  at  least,  as  an 
open  question. 

The  rule  has  been  to  attribute  insanity  (when  developed  during 
the  existence  of  uterine  or  ovarian  disease)  to  reflex  action.  The 
well-known  book  by  Dr.  H.  K.  Storer  affords  a  notable  example  of 
the  position  given  to  reflex  action  in  the  etiology  of  insanity.  This, 
no  doubt,  is  an  important  factor  in  the  cause  of  mental  derangement, 
but  it  is  far  from  covering  the  whole  ground.  An  acute  disease  of 
the  ovary  or  uterus,  or  a  displacement  of  either,  is  sufficient  to 
cause  a  mental  derangement  (in  some  highly  sensitive  organizations) 
which  will  subside  when  the  disease  of  the  pelvic  organ  is  relieved. 
Such  cases  are  no  doubt  reflex  in  character,  but  there  are  a  great 
many  more  cases  of  insanity  that  can  be  traced  to  the  sexual  organs 
in  which  reflex  action  takes  no  part.  Take,  for  example,  cases  of 
uterine  disease,  preceding  by  an  interval  of  years  the  mental  de- 
rangement which  follows  without  any  increase  of  the  primary  disease. 
In  such  cases  it  is  probable  that  impaired  nutrition  of  the  brain, 
which  occurs  as  the  result  of  prolonged  sufliering,  is  the  direct  cause 
of  insanity,  and  not  the  result  of  reflex  action  from  the  disease  of 
the  sexual  organs.  The  irritation  and  exhaustion  produced  by  uter- 
ine or  ovarian  disease  is  simply  the  predisposing  indirect  cause  of 
the  insanity,  while  the  direct  cause  is  some  lesion  of  nutrition  of  the 
brain  itself. 

One  of  the  most  marked  and  important  causes  of  insanity 
among  women  of  the  poorer  class  is  frequent  child-bearing  and 
lactation.  The  extraordinary  taxation  imposed  by  their  maternal 
duties  deranges  the  mind  of  a  vast  number  of  women.  This  fact 
is  quite  familiar  to  medical  men,  and  has  been  proved  to  my  own 
satisfaction  by  clinical  observation,  and  a  perusal  of  the  records  of 
all  the  asylums  in  this  country.  From  these  reports  I  find  that 
the  largest  number  of  insane  women  is  found  at  from  twenty-five 
to  forty  years  of  age,  and  that  of  these  a  large  percentage  have 
been  married  and  have  had  children.  Of  this  number,  some  may 
have  had  disease  of  the  sexual  organs,  but  there  can  be  no  doubt  that 
a  large  number  become  insane  from  the  exhaustion  of  frequent  child- 
bearing  and  lactation,  without  any  other  complications.  These  cases 
of  insanity  can  be  traced  indirectly  to  extraordinary  functional  activ- 


932  DISEASES   OF  WOMEN". 

ity  of  the  sexual  organs,  but  can  not  be  called  cases  of  reflex  insani- 
ty. There  is  a  difficulty  in  turning  the  records  of  asylums  to  account 
because  they  are  not  kept  so  as  to  bring  out  the  history  of  the  sexual 
organs,  or  the  relation  of  their  diseases  to  insanity.  Nevertheless, 
there  are  facts  sufficient  to  show  that  child-bearing  and  lactation  bear 
an  important  relation  to  mental  disorders. 

There  is  too  little  in  om*  literature  on  the  subject  of  mania 
caused  by  the  exhaustion  of  the  nervous  system  from  child-bearing 
and  nursing.  The  true  bearing  of  the  sexual  organs  in  this  connec- 
tion is  liable  to  escape  notice,  because  the  mental  weakness  or  nerv- 
ous exhaustion  is  the  first  manifestation  of  disease.  There  is  no 
uterine  or  ovarian  disease  to  attract  the  physician's  attention  while 
he  is  seeking  for  the  cause  of  mania.  Our  books  tell  us  of  angemia 
from  prolonged  lactation,  but  say  little  of  the  nervous  exhaustion 
which  may  or  may  not  be  accompanied  by  anaemia. 

Every  practitioner  has  observed  the  conditions  of  mental  depres- 
sion and  nervous  irritation  and  debility  which  occur  during  the 
child-bearing  period  of  women's  life.  We  may  go  beyond  the 
apparent  effects  of  rapid  and  long-continued  reproduction  and  ask 
the  question.  Why  should  the  exercise  of  this  normal  function  so 
often  sacrifice  the  mental  and  physical  health  of  woman?  The 
answer  is,  that  too  many  other  duties  are  usually  imposed  upon 
women  during  the  age  of  reproduction.  Among  the  poor  the  wife 
is  required  to  work  for  her  livehhood,  as  well  as  to  give  life  and 
sustenance  to  her  children ;  even  among  the  rich  we  often  find 
that  very  little  allowance  is  made  for  maternal  duties.  These  com- 
bined exertions  of  reproduction  and  e very-day  labor  to  which  so 
many  women  are  subjected,  are  more  than  the  strongest  constitution 
can  endure.  This  will  be  granted  by  the  most  fanatical  behever  in 
the  mental  and  physical  capabilities  of  women.  It  may  be  ques- 
tioned if  even  physicians  at  all  times  fully  appreciate  the  demand 
made  upon  the  female  organization  by  reproduction.  During  preg- 
nancy, there  is  often  an  apparent  or  real  increase  in  the  nutrition  of 
the  individual,  which  gives  the  highest  evidence  of  good  health ; 
there  is  also  a  manifest  ability  to  do  ordinary  work  that  is  surprising. 
But  if  this  power  is  abused,  as  it  often  is,  the  result  must  be  general 
debility.  The  resistance  to  this  overtaxation  may  be  and  often  is 
maintained  for  a  long  time.  The  first  pregnancy  and  lactation  do 
not  necessarily  break  down  the  constitution,  but  the  repetition  of 
these,  "with  the  duties  and  cares  which  multiply  as  life  advances, 
exhaust  the  nerve  power,  and  lead  in  many  cases  to  mental  derange- 
ment.    This  is  especially  so  among  those  who  have  been  raised  in 


GYNECOLOGY  AS  RELATED   TO  INSANITY  IN   WOMEN.    933 

ease  and  comfort  without  acquiring  habits  of  industry.  When 
daughters  of  these  famihes  marry  into  less  affluent  circumstances,  or 
when  Fortune  turns  against  the  young  wife  and  mother,  and  disap- 
pointment and  privation  are  added  to  the  taxation  of  household 
duties  and  the  raising  of  a  family,  then  we  have  all  the  conditions 
necessary  to  cause  insanity.  Many  cases  having  such  a  history  can 
be  found  in  our  asylums.  The  insanity  occurring  under  sucli  cir- 
cumstances is  generally  centric  and  not  reflex,  and  yet  dependent  to 
some  extent  ou  the  sexual  organs. 

Many  authorities  might  be  quoted  to  prove  that  the  normal  func- 
tional activity  of  the  reproductive  organs  sometimes  tends  to  under- 
mine the  brain  and  nervous  system  to  an  extent  sufficient  to  lead  to 
insanity,  and  I  am  satisfied,  from  cases  occurring  in  my  own  prac- 
tice, that  it  occasionally  does  so. 

There  is  a  prevailing  opinion  that  insanity  occurs  very  frequently 
at  puberty,  and  the  cause  in  such  cases  is  generally  ascribed  to  reflex 
action.  This,  no  doubt,  is  frequently  the  true  cause,  but  not  always. 
Mental  and  emotional  excitement  occurring  in  connection  with  de- 
mands of  the  reproductive  system  abruptly  made  at  that  time, 
may  develop  insanity  at  puberty,  when  the  sexual  organs  are  well 
developed  and  perform  the  function  of  menstruation  normally. 
Again,  insanity  occurring  at  the  menopause,  in  place  of  being  due 
to  disease  of  the  sexual  organs,  can  often  be  traced  to  deranged  con- 
ditions of  the  general  system,  such  as  imperfect  elimination,  or  as  the 
older  authors  state,  the  sudden  suppression  of  an  accustomed  discharge. 

There  are  other  causes  of  insanity,  such  as  the  puerperal  state 
and  venereal  excesses,  which  are  fully  discussed  in  our  books  and 
need  not  be  mentioned  here.  Enough  has  been  said  to  show  that 
a  clear  distinction  should  be  made  in  the  study  of  etiology,  between 
insanity  caused  by  existing  active  disease  of  the  sexual  organs,  and 
insanity  arising  from  brain  exhaustion  produced  by  prolonged  or 
excessive  fimctional  activity  of  these  organs  while  free  from  any 
disease.  We  incline  to  the  belief  that  as  many  or  even  more  cases 
of  insanity  can  be  traced  to  the  latter,  i.  e.,  exhausting  activity,  as  to 
the  former,  i.  e.,  active  disease  of  the  sexual  organs.  The  bearing 
of  these  facts  upon  the  diagnosis  and  treatment  of  insane  women 
will  be  apparent  to  all  medical  men.  In  the  one  class  of  cases  the 
sexual  organs  require  no  attention,  except  as  factors  in  the  indirect 
cause  of  the  mental  affection ;  while  in  the  other  the  disease  of  the 
sexual  organs  is  the  direct  cause  of  insanity,  and  tends  to  keep  it  up 
until  removed  by  the  treatment  which  ought  in  all  cases  to  be  insti- 
tuted. 


934  DISEASES   OF  WOMEN.     • 

Having  briefly  referred  to  some  of  the  influences  of  the  sexual 
organs  in  causing  insanity,  the  next  question  which  I  propose  to 
discuss  is  the  effect  of  insanity  upon  the  function  of  the  reproduc- 
tive system.  Observations  were  made  on  two  hundred  women  rang- 
ing in  age  from  seventeen  to  forty-six  years,  the  period  of  active 
functional  life  of  the  sexual  organs.  These  observations  w^ere  contin- 
ued during  six  months,  and  at  the  end  of  that  time  eight  were  lost, 
some  by  death,  and  the  others  discharged  from  the  asylum.  Of  the 
remaining  192,  there  were  only  27  who  menstruated  regularly  and 
normally ;  30  did  not  menstruate  at  all ;  4  menstruated  once ;  8 
twice ;  10  three  times ;  18  four  times ;  34  Ave  times ;  24  six  times 
at  irregular  intervals ;  31  seven  times,  and  6  eight  times  during  the 
six  months.  This  record  shows  to  what  a  marked  extent  the  men- 
strual function  is  disturbed  among  insane  women.  There  are  per- 
haps other  conditions  in  which  two  hundred  women  possessing  the 
same  degree  of  physical  health  could  be  found  with  menstrual 
derangements  to  the  same  extent.  These  disorders  of  menstruation 
are  accounted  for  in  two  ways.  The  impaired  general  nutrition 
w^hich  prevails  so  extensively  among  the  insane  is  sufficient  to  arrest 
the  menses  in  a  large  proportion  of  cases.  The  general  health  is 
reduced  so  far  below  the  normal  standard,  as  to  compel  the  indi- 
vidual to  suspend  all  functional  activity  not  absolutely  necessary  to 
life.  The  same  symptoms  occur  in  any  of  the  exhausting  diseases, 
such  as  phthisis  pulmonalis,  as  every  physician  well  knows.  The 
amenorrhoea  is  conservative  when  it  occurs  under  such  circum- 
stances, and  should  not  be  considered  abnormal,  but  as  a  fortunate 
provision  of  Nature  to  relieve  an  overtaxed  organization  from  a  duty 
which  can  be  neglected  with  less  injury  to  the  individual  than  any 
other  function.  That  the  suspension  of  menstruation  is  caused  by 
malnutrition,  is  evident  from  the  fact  that  the  same  condition 
occurs  in  other  diseases  when  the  nutrition  is  markedly  impaired. 
Additional  proof  is  also  obtained  from  the  fact  that  the  sexual 
organs  in  such  cases  are  generally  found  to  be  anaemic,  presenting 
the  appearance  of  those  who  have  passed  the  menopause,  except 
that  there  is  not  always  atrophy  such  as  we  find  in  the  very  aged. 
A  sufficient  number  of  the  cases  having  suppression  of  the  menses 
that  are  recorded  in  the  table  were  carefully  investigated  to  show 
that  there  was,  in  most  of  them,  impaired  nutrition  of  the  sexual 
organs,  to  account  for  the  amenorrhoea.  On  the  other  hand,  amen- 
orrhoea finds  its  cause  in  the  diseased  nervous  system  alone.  A  few 
cases,  and  especially  one,  came  under  observation  in  which  the  gen- 
eral nutrition  was  normal,  the  pelvic  organs  were  in  a  healthy  con- 


GYNECOLOGY  AS  RELATED  TO   INSANITY  IN  WOMEN,    935 

ditioii,  and  still  there  was  ainenorrhoea  due,  beyond  doubt,  to  imper- 
fect innervation.  An  abundance  of  proof  could  be  brought  forward 
to  show  that  the  deranged  innervation,  such  as  occurs  among  the 
insane,  causes  suspension  of  the  function  of  the  sexual  organs ;  but 
it  will  suffice  to  recall  the  fact  that  mental  shocks,  prolonged  mental 
anxiety,  and  the  like  have  been  long  recognized  as  causes  of  acute 
suppression  of  the  menses.  Cases  without  number  are  on  record 
which  establish  this  fact. 

As  a  number  of  patients  wbo  came  under  my  care  menstruated 
regularly  and  some  of  them  had  menorrhagia,  or  too  frequent  men- 
struation, the  question  arises.  Why  was  that  the  case,  all  of  the  pa- 
tients being  insane  ?  According  to  the  rule  forced  upon  us,  that  in- 
sanity tends  to  suspend  the  menstrual  function,  all  the  insane  should 
have  amenorrhoea,  but  they  do  not.  The  answer  then  is,  that  men- 
struation is  affected  in  proportion  to  the  degree  of  insanity.  In 
those  patients  who  menstruated  norinally  the  insanity  was  of  a  mild 
type,  not  sufficient  to  impair  either  the  nutrition  or  the  innervation 
of  the  pelvic  organs  to  any  marked  extent ;  and  in  those  who  suf- 
fered from  menorrhagia,  or  too  frequent  menstruation,  there  was 
some  form  of  uterine  disease  present. 

The  deductions  drawn  from  the  phenomena  observed  may  be 
formulated  as  follows  :  Well-developed  insanity,  with  impaired  gen- 
eral nutrition,  causes  suppression  of  the  functions  of  the  sexual  or- 
gans. Deranged  innervation  tends  to  produce  the  same  result.  In 
mild  forms  of  insanity  menstruation  may  continue  normal.  Excess- 
ive menstruation  among  the  insane  is  usually  caused  by  uterine  dis- 
ease, and  should  be  accepted  as  evidence  of  such. 

The  opinion  just  stated  is  based  upon  clinical  observations  of  the 
menstrual  function,  which  may  be  taken  to  a  great  extent  at  least  as 
an  index  of  the  condition  of  the  organs  concerned.  It  can  not,  how- 
ever, be  claimed  that  amenoiThoea  is  a  sure  indication  that  all  the 
functions  of  the  sexual  organs  are  suspended.  We  know  well  that 
ovulation  may  continue,  while  menstruation  is  absent,  and  so  may 
the  venereal  desire ;  but  such  cases  are  exceptional.  JMoreover, 
there  are  other  reasons  for  beheving  that  a  general  functional  inac- 
tivity prevails  in  those  cases  characterized  by  amenorrhoea.  In  a 
few  cases  of  this  class,  when  a  post-mortem  examination  has  been 
made,  the  evidences  of  ovulation  have  been  absent.  More  facts  are 
needed  to  fully  establish  this  point ;  still  enough  have  been  obtained 
to  show  that  ovulation  is  arrested  in  some  cases  of  insanity.  Again, 
maternal  and  marital  affections  (ruling  passions  in  women)  are,  as  a 
rule,  rarely  manifested  by  this  class  of  insane  women.     This  would 


936  DISEASES   OF  WOMEX. 

also  tend  to  prove  that  the  sexual  organs  return  for  the  time  to  a 
condition  of  functional  inaction  resembling  that  of  childhood  or  ad- 
vanced age. 

Trusting  that  sufficient  evidence  has  been  produced  regarding 
the  influence  of  insanity  upon  the  function  of  the  sexual  organs,  the 
question  which  follows  in  succession  is,  What  effect  does  insanity- 
exert  upon  their  diseases  ( 

We  shall  first  take  up  the  functional  diseases  of  the  uterus,  and, 
according  to  the  necessities  arising  from  the  character  of  our  nomen- 
clature, we  must  include  under  this  head  all  those  affections  in  which 
the  function  of  the  organ  is  deranged  because  of  an  impaired  inner- 
vation and  blood  circulation. 

It  appears  that  all  authorities  upon  uterine  pathology  agree  that, 
in  a  host  of  cases  of  uterine  diseases  met  in  practice,  there  exists  an 
excess  of  nerve  irritability  and  hyperemia,  without  any  well-defined 
change  in  the  structure  of  the  tissues  excepting  that  which  occuj'S  in 
all  pathological  congestions — a  condition  which  implies  a  change  in 
the  quantity  of  blood  and  caliber  of  the  vessels,  which  is  not  perma- 
nent, but  disappear  under  influences  which  enable  the  vessels  to  re- 
gain their  original  size  and  tonicity.  This  class  of  diseases  is  dis- 
tinct from  the  organic,  in  which  well-defined  and  easily  recognized 
changes  of  structure  exist.  For  want  of  a  more  comprehensive  and 
accurate  name  these  are  called  functional  affections. 

The  influence  of  insanity  on  this  class  of  diseases  is  most  favor- 
able. It  may  be  stated  fairly  that  such  diseases  disappeai*  upon  the 
occurrence  of  mental  alienation.  To  use  a  popular  but  unscientific 
expression,  insanity  tends  to  cure  functional  diseases  of  the  uterus. 
This  statement  may  excite  question  and  opposition,  but  clinical  ob- 
servation compels  this  conclusion  and  renders  it  worthy  of  the  high- 
est consideration.  It  should  be  clearly  borne  in  mind  that  the  influ- 
ence of  insanity  does  not  extend  beyond  this  class  of  diseases,  that  it 
does  not  affect  organic  diseases  to  the  same  extent  at  least.  This  is 
not  claimed  by  any  means ;  but  the  effect  upon  the  functional  forms 
of  disease  is  marked,  and,  we  think,  unquestionable.  There  ai-e  ex- 
ceptional cases  no  doubt,  but  the  rule  holds  good.  The  subjects  of 
masturbation  and  those  who  labor  under  a  mental  derangement  of  a 
venereal  kind,  while  free  from  uterine  and  ovarian  disease,  have  cen- 
tric affections  only,  and  belong  to  a  class  to  be  referred  to  at  another 
time. 

Attention  was  first  directed  to  this  subject  by  watching  the  pro- 
gressive history  of  a  case  which  was  under  observation  for  conges- 
tion of  the  uterus  and  leucorrhoea.     She  became  insane,  and  her 


GYNECOLOGY  AS  RELATED  TO  INSANITY  IN  WOMEN.    937 

uterine  disease  disappeared  without  local  treatment.  The  disease  of 
the  uterus,  added  to  other  causes  of  mental  disturbance,  was  sup- 
posed to  have  acted  a  part  in  the  causation  of  her  insanity.  Other 
cases  followed  this  one,  until  sufficient  material  was  obtained  to  show 
the  relationship  of  the  mental  and  uterine  disease.  Some  cases,  in- 
deed quite  a  few,  whose  history  of  former  uterine  diseases  I  obtained 
through  friends,  when  examined  in  the  asylum  were  found  to  have 
recovered.  The  disappearance  of  functional  uterine  disease  upon 
the  occurrence  of  insanity  agrees  with  the  facts  observed  regarding 
the  influence  of  mental  alienation  on  the  function  of  the  sexual  or- 
gans. That  the  vital  activity  of  an  organ  or  system  can  be  lowered 
by  the  influence  of  disease  existing  elsewhere  in  the  organization  to 
an  extent  sufficient  to  cause  arrest  of  function  is  evidence  that  func- 
tional disease  may  disappear  under  the  same  circumstances.  The 
same  action  is  observed  in  the  pathology  of  other  diseases.  The  lit- 
erature of  medicine  furnishes  numerous  illustrations  of  the  fact  that 
disease  in  one  portion  of  the  body  may  disappear  upon  the  develop- 
ment of  morbid  action  in  another.  This  is  all  comprehended  under 
the  head  of  the  antao-onism  of  diseases,  the  same  law  which  i-ecos:- 
nizes  the  physiological  antagonism  of  medicines.  It  is  not  claimed 
that  all  functional  disease  of  the  uterus  disappears  when  insanity  is 
developed  ;  but  this  occurs  so  generally  that  those  cases  in  which  the 
uterine  derangements  persist  may  be  classed  as  exceptional. 

This  peculiarity  of  uterine  disease  among  the  insane  has  prob- 
ably led  psychologists  to  attach  but  little  importance  to  uterine 
disease  as  complicating  mental  affections.  This  is  the  only  reason 
or  excuse  for  those  who  claim  that  the  sexual  organs  require  but 
little  notice  from  those  who  have  the  care  of  insane  patients.  Such 
observers  have  caught  a  fraction  of  the  truth,  and  endeavor  to  make 
it  cover  more  ground  than  belongs  to  it.  The  influence  of  insanity 
in  arresting  the  progress  of  uterine  disease  relates  almost  exclusively 
to  the  class  of  affections  above  stated,  and  does  not  apply  to  other 
forms  of  local  disease  of  an  organic  character.  Those  who  claim 
much  more  are  as  far  from  the  right  as  the  gynecologist,  who  be- 
lieves that  the  great  majority  of  women  who  lose  their  reason  do  so 
because  of  disease  of  the  sexual  organs,  and  that  all  insane  women 
should  be  placed  in  charge  of  the  specialist  for  diseases  of  women. 

The  class  of  insane  women  who  have  simply  functional  diseases 
of  the  sexual  organs  requires  no  care  from  the  gynecologist,  beyond 
what  is  necessary  to  establish  the  fact  that  there  exists  no  organic 
disease.  This  in  itself  is  an  important  service,  and  one  which  only 
the  gynecologist  can  render ;  but  when  the  diagnosis  is  settled  in 


938  DISEASES  OF  WOMEN. 

the  negative,  the  patient  should  be  left  to  the  psychologist.  The 
reHef  of  deranged  menstruation  and  functional  diseases  must  come 
through  improvement  of  the  general  health  and  the  cure  of  the 
insanity,  and  not  by  any  local  treatment,  except  hygienic,  and  this 
the  alienist  is  as  competent  to  afford  as  the  gynecologist. 

The  same  rule  of  practice  should  be  followed  in  the  management 
of  this  class  of  patients  that  is  observed  in  cases  in  which  the  func- 
tion of  the  sexual  organs  is  deranged  from  any  other  disease  of  the 
general  system,  like  pulmonary  phthisis,  nervous  exhaustion,  and 
such  like ;  i.  e.,  to  restore  the  general  system  to  health,  and  trust 
that  restoration  of  the  sexual  organs  will  follow. 

There  is  one  class  of  insane  patients,  already  referred  to,  in 
which  there  appears  to  be  a  functional  derangement  of  the  sexual 
organs,  which  would  apparently  call  for  the  gynecologist's  care ; 
viz.,  those  who  manifest  insane  sexual  desire,  or  whose  ravings  are 
obscene  and  licentious.  Such  cases  often  take  their  origin  in  some 
disease  or  abuse  of  the  sexual  organs,  which  either  disappears  or 
eludes  the  diagnostic  skill  of  the  gynecologist. 

While  the  mental  derangement  points  to  trouble  of  the  pelvic 
organs,  no  disease  can  be  detected.  Local  treatment  in  such  cases 
can  eifect  no  benefit,  because  the  disease  is  centric  and  not  reflex ; 
hence  the  treatment  must  be  directed  to  the  nervous  system.  When 
it  is  stated  that  manifestations  of  sexual  excitement  may  originate  in 
the  brain  or  nervous  system,  we  have  clearly  in  mind  that  the  same 
symptoms  may  arise  from  disease  of  the  pelvic  organs,  and  will 
refer  to  that  class  of  cases  at  another  time.  We  take  the  ground 
that  abnormal  sexual  excitement  sometimes  has  its  origin  in  the 
nerve  centers,  and  that  too  when  the  sexual  organs  are  free  from 
disease,  and  that  a  mental  derangement  of  an  emotional  character 
may  continue  after  the  disease  which  caused  it  has  subsided.  The 
importance  of  clearly  distinguishing  diseases  of  the  sexual  organs 
that  cause  and  tend  to  keep  up  insanity,  and  mental  derangements, 
which  exist  independent  of  lesions  of  other  organs,  can  hardly  be 
overestimated. 

Organic  diseases  of  the  sexual  organs  exercise  a  most  important 
influence  in  causing  insanity,  and  tend  to  retard  recovery  from  it. 
Under  that  head  are  included  all  the  appreciable  diseases  of  the 
ovaries,  uterus,  and  vagina,  that  are  charactei'ized  by  change  of 
structure  or  position.  These  need  not  be  named  individually,  but  I 
may  mention  some  conditions  that  are  more  properly  called  results 
or  products  of  disease,  in  contradistinction  to  active  morbid  pro- 
cesses.    Such  are  the  products  of  pelvic  peritonitis  and  cellulitis, 


GYNECOLOGY  AS  RELATED  TO   INSANITY  IN  WOMEN.    939 

cicatrices  of  the  cervix  and  vagina.  These,  by  adhesion  and  con- 
tractions, often  cause  severe  pelvic  pains,  sufficient  to  induce  or 
keep  up  insanity. 

These  affections  of  the  sexual  organs  frequently  cause  insanity 
directly  or  indirectly,  and  unlike  functional  diseases,  are  not  as  a 
rule  relieved  by  the  mental  derangement  which  follows.  It  is  evi- 
dent that  no  disease  of  the  brain  or  nervous  system  could  favorably 
influence  a  displacement  of  the  uterus  or  the  ovaries,  nor  modify  the 
ill-effects  of  a  laceration  of  the  cervix,  nor  check  a  leucorrhoea  due 
to  that  lesion  of  the  organ.  On  the  contrary,  insanity  which  too 
often  debars  the  sufferer  from  requisite  treatment,  and  even  the 
care  that  she  would  take  to  favor  her  infirmities  while  in  sound 
mental  health,  tends  to  prolong  if  not  to  aggravate  the  pelvic 
disease.  These  diseases  of  the  sexual  organs  remain  as  a  disturbing 
element  to  keep  up  the  derangement  of  the  brain,  or  at  least  to 
retard  recovery.  In  this  way  the  insanity  and  the  disease  of  the 
sexual  organs  act  in  concert  to  maintain  each  other  to  the  detriment 
of  the  unfortunate  sufferers.  There  are  but  few  cases  in  this  class, 
where  the  disease  of  the  pelvic  organs  can  be  lessened  in  severity  by 
the  presence  of  insanity.  The  general  anaesthesia  which  occurs  in 
some  forms  of  insanity  may  relieve  the  patient  from  the  suffering 
of  pelvic  pain  arising  from  old  adhesions.  So  also  a  dysmenorrhoea, 
which  is  largely  due  to  an  exalted  nerve  irritability,  may  be  modi- 
fied or  entirely  relieved.  In  prolapsus  of  the  ovaries  and  chronic 
ovaritis,  the  pain  may  be  calmed  by  the  mental  derangement  as  by 
opium,  but  still  in  such  cases,  although  the  patient  appears  to  suffer 
less,  the  question  may  be  asked :  Does  not  the  disease  exert  as  pow- 
erful an  energy  for  evil  upon  the  brain  and  nervous  system  of  the 
sufferer?  It  is  possible  that  while  the  patient  is  so  fully  engaged 
with  insane  fancies  as  to  disregard  physical  pain,  the  local  irritation 
exists  none  the  less,  exercising  its  depressing  influence.  Be  this  as 
it  may,  it  is  certain  that  whenever  disease  exists  in  the  sexual  organs 
of  insane  women,  the  condition  of  the  brain,  if  influenced  thereby 
at  all,  must  be  affected  unfavorably.  If  such  diseases  of  the  sexual 
organs  are  capable  of  causing  insanity,  (a  fact  that  appears  to  be 
settled  by  our  best  thinkers  on  both  sides)  they  must  also  tend  to 
keep  it  up.  It  is  to  this  class  of  genital  affections  among  the  insane, 
that  the  science  and  art  of  gynecology  apply  with  most  marked 
advantage.  Functional  derangements  and  diseases  of  the  sexual 
organs  among  the  insane  may  be  left  alone,  and  the  patients  com- 
mitted to  the  psychologist,  with  confidence  that  they  will  secure,  all 
the  benefits  that  medical  science  can  afford.     In  this  department 


940  DISEASES   OF  WOMEN. 

those  who  care  for  the  insane  may  insist  npon  non-interference  from 
us.  But  when  insane  women  have  organic  diseases,  thej  have  a 
right  to  all  the  relief  that  they  can  obtain  from  gynecology,  and 
that  is  certainly  very  much. 

Another  question  follows  at  this  point :  What  are  the  ascertained 
effects  upon  the  insane  of  curative  treatment  of  the  co-existing 
diseases  of  the  sexual  organs  ? 

Any  one  who  is  familiar  with  our  current  literature  would,  on 
first  thought,  be  prompted  to  say  that  the  results  are  very  gratifying, 
— even  wonderful.  There  are  cases  recorded  without  number  in 
which  all  varieties  of  strange  nervous  affections  and  mental  dis- 
orders have  disappeared  as  if  by  magic,  upon  the  replacement  of  a 
dislocated  uterus,  or  the  restoration  of  a  lacerated  cervix.  Much  of 
this  literature  may  be  worthy  of  acceptance  as  exact  science,  but 
there  is  much  of  it  that  may  be  challenged  as  having  no  other  claims 
upon  our  notice  than  the  fact  that  recovery  of  one  affection  followed 
the  cure  of  an  accompanying  one  ;  but  what  relation  the  one  had  to 
the  other  remains  a  mystery.  To  accept  all  such  testimony  as  cor- 
rect, would  be  as  unsafe  as  to  believe  that  sense  and  reason  could  be 
promptly  restored  to  all  insane  women  by  curing  any  disease  of  the 
sexual  organs  that  they  had. 

A  careful  consideration  of  this  subject  has  led  to  the  conclusion 
that  acute  affections  of  the  brain  and  nervous  system,  that  are  wholly 
due  originally  to  disease  of  the  sexual  organs,  will  be  relieved,  in  a 
large  majority  of  cases,  by  curing  the  primary  affection.  The  effects 
of  treatment  of  the  disease  of  the  sexual  organs  will  be  in  proportion 
to  the  duration  and  severity  of  the  mental  derangement.  In  sub- 
acute mania,  caused  or  aggravated  by  disease  of  the  sexual  organs, 
marked  benefit  or  prompt  recovery  may  be  expected  to  follow  the 
cure  of  the  pelvic  disease.  On  the  other  hand,  chronic  mania  asso- 
ciated with  disease  of  the  sexual  organs,  will  often  remain  unchanged 
after  the  local  disease  has  been  reheved.  Tliat  is  sometimes  the  case 
when  the  patient's  general  health  improves  by  the  local  treatment. 

This  follows  the  rule  that  is  observed  in  other  departments  of 
pathology,  in  which  two  or  more  diseases  are  related  to  each  other 
in  the  order  of  cause  and  effect.  A  secondary  disease  does  not 
always  disappear  when  the  primary  one,  which  acted  as  the  cause  of 
the  other,  is  cured.  This  defines  the  limits  of  the  success  which  the 
gynecologist  may  expect  to  have  in  practice  among  the  insane. 

Having  endeavored  to  outline  the  conditions  which  demand 
the  service  of  the  gynecologist  among  the  insane,  attention  is  now 
invited  to  the  subject  of  diagnosticating  diseases  among  this  class  of 


GYNECOLOGY   AS  EELATED  TO  INSANITY   IN  WOMEN.   941 

patients.  The  rules  laid  down  in  our  te:^t-books  on  diseases  of 
women  for  investigating  pathological  conditions  apply  to  practice 
among  the  insane  only  in  part. 

There  is  an  endless  number  of  difficulties  which  are  not  en- 
countered among  sane  women.  To  overcome  these  and  find  means 
and  ways  of  ascertaining  the  clinical  history  and  physical  indications 
of  the  state  of  the  sexual  organs,  has  occupied  much  of  my  study, 
and  the  results  I  now  offer. 

The  first  thing  required  is  the  natural  and  clinical  history  of  the 
sexual  system.  Very  few  insane  patients  can  give  an  account  of 
themselves  in  this  respect ;  even  those  who  comprehend  questions 
and  are  disposed  to  answer  them,  are  often  opposed  to  discussing 
their  uterine  conditions,  and  when  they  can  be  induced  to  talk  on 
the  subject,  the  physician  is  left  in  doubt  as  to  the  correctness  or 
value  of  their  testimony.  We  are  obliged,  therefore,  to  depend  upon 
the  methods  employed  in  the  investigation  of  diseases  in  childi'en, 
and  seek  information  from  those  who  have  had  the  care  of  the 
patients.  Parents,  friends,  and  nurses  can  generally  give  us  the  facts 
that  we  require  to  know.  By  diligent  inquiry  in  tliis  way,  the  lead- 
ing points  in  the  history  of  the  patient  up  to  the  development  of  in- 
sanity can  be  usually  learned,  and  if  the  attention  of  the  nurse  or 
guardian  is  directed  to  a  careful  observation  of  the  function  of  the 
sexual  organs,  much  valuable  knowledge  can  be  obtained.  Atten- 
tion is  especially  directed  to  this  part  of  the  clinical  history  of 
insane  patients,  because  it  is  sadly  neglected  by  the  great  majority  of 
those  who  have  the  care  of  them.  In  looking  over  the  records  kept 
in  the  asylums  one  can  see  how  little  information  they  afford  regard- 
ing the  state  of  the  organs  of  reproduction.  The  age  of  patient,  and 
whether  married  or  single,  and  the  number  of  children,  if  any,  that 
she  has  had,  is,  in  many  institutions,  all  that  bears  upon  gynecology. 

For  example,  in  the  tables  of  nearly  all  the  asylums  for  insane 
people  in  this  country,  we  find  that  those  showing  the  age  at  which 
insanity  first  appeared,  give  the  number  of  those  under  ten,  from 
ten  to  fifteen,  from  fifteen  to  twenty,  and  so  on ;  or  else  they  are 
arranged  under  twenty,  and  from  twenty  to  thirty,  thirtj"  to  forty, 
etc.  Tills  shows  how  impossible  it  is  for  any  one  to  obtain  from 
such  tables  the  information  which  the  gynecologist  needs,  on  the 
relations  of  puberty  and  the  menopause  to  insanity.  These  records 
may  give  the  information  required  by  the  psychologist,  but  are  of 
little  value  for  our  purpose.  To  know  the  condition  of  the  sexual 
organs,  we  require  all  available  information  regarding  their  func- 
tional manifestations.     In  order  to  accomplish  this,  I  arranged  a 


942  DISEASES  OF   WOMEN, 

ease-book  for  use  in  our  county  asylum,  which  was  approved  by  the 
medical  director,  Dr.  Shaw.  The  headings  in  the  blank  pages  are 
so  arranged  as  to  call  out  the  history  bearing  upon  the  condition  of 
the  sexual  system,  etc.  Here  is  the  history  of  a  case  as  it  reads  from 
this  form  of  record : 

Date. 

Name,  A M Age,  30.  Nativity,  Oermany. 

Temperament,  Sanguine,  Nervous.  Diathesis,  None. 

i  Mental,  Good. 
Inherited  Disease,  None. 
Physical,  Fair. 
Social  condition.     Married  eleven  years.  No.  of  Children,  7. 

Age  of  first,  10.  Age  of  last,  S-J  ms. 

Miscarriages,  Period  of  Gestation,  Date  of  first.  Date  of  last. 

Character.  Eecurrence. 

Normal.      Every  28  days. 
Absent. 

Effect  of  Menses  on  Nervous  System  before  insanity.  No  effect  observed. 
Effect  of  Menses  on  Nervous  System  after  insanity,  Not  observed. 
History  of  Disease  of  Sexual  Organs  before  insanity.  Normal  until  after  her  fifth  child, 

when  she  had  slight  prolapsus  of  the  uterus  and  bladder. 
Mental  manifestations  and  Symptoms  of  Disease  of  the  Sexual  Organs.     Complained  of 
weakness,  while  nursing  her  last  three  children.     She  walks  in  a  stooping  position  ; 
has  leucorrhoea,  and  states  that  there  is  something  in  her  ivomb  which  ought  to  come 
away. 
Physical  signs  of  Disease  of  Sexual  Organs,  Uterine  cavity  three  and  three  fourths  inches 
long.     Slight  eversion  of  cervix  ;  anteversion  of  the  uterus  ;  prolapsus  of  the  urethra  and 
bladder. 

Diagnosis,  Imperfect  involution  and  anteversion  of  the  uterus.     Eversion  of  the  cervix 
from  slight  laceration  ;  prolapsus  of  the  bladder  and  urethra. 
Form  of  Insanity,  Melancholia. 


Menses,  j  Before  insanity, 

First  at  16,  <  After  insanity, 


Duration. 
5  to  6  days. 


Amount. 
Normal. 


iof  Insanity,  Five  montlis. 
of  disease  of  Sexual  Organs,  Began  at  the  birth  of  her  third  child,  and  increased 
at  her  last  confinement  eight  and  a  half  months  ago. 
!of  Insanity,  Exhaustion  from  reproduction  and  overivork. 
of  disease  of  Sexual  Organs,  Debility,  and  resuming  her  every-day  labor  too 
soon  after  confinement. 

A  part  of  this  history,  you  observe,  was  obtained  from  the  mother 
of  the  patient,  who  also  furnished  some  valuable  facts  regarding  her- 
self ;  the  rest  is  added  by  the  medical  attendant. 

Such  a  record  supplies  the  required  information  for  the  use  of 
the  gynecologist,  and,  although  it  may  not  be  the  best  attainable, 
we  venture  to  state  that  it  is  better  for  the  purpose  than  the  records 
usually  kept  in  such  institutions,  and  it  is,  therefore,  commended 
to  those  in  charge  of  insane  women  who  desire  to  avail  themselves 
of  the  aid  of  those  skilled  in  the  treatment  of  the  diseases  of  women. 


GYNECOLOGY  AS  RELATED   TO   INSANITY   IN  WOMEN.    943 

The  design  of  this  method  of  making  clinical  histories  is  to  ascer- 
tain, as  far  as  possible,  the  condition  of  the  sexual  organs  before 
insanity  occurred,  and  the  relation  of  the  mental  derangement  to  the 
functions  of  reproduction.  Then  follows  the  history  of  the  function 
of  these  organs  as  shown  by  the  condition  of  the  menstrual  function. 
Lastly,  the  observance  of  such  mental  manifestations  as  may  indicate 
the  existence  of  disease  of  the  sexual  organs.  Under  this  head  much 
valuable  information  may  be  obtained  by  carefully  studying  the  pa- 
tient's speech  and  behavior.  This  portion  of  the  subject  may  be 
brought  out  more  clearly  by  a  few  details. 

Dr.  Shaw  called  my  attention  to  one  girl  who  walked  about  the 
ward  in  a  stooping  position,  and  held  her  hands  upon  the  genitals  as 
if  trying  to  support  them.  She  made  no  complaint,  nor  was  she 
sane  enough  to  answer  questions  about  herself,  but  her  actions  raised 
the  suspicion  that  there  was  something  wrong,  and,  upon  examina- 
tion, she  was  found  to  have  uterine  disease.  Another  case,  a  mar- 
ried woman,  and  the  mother  of  children,  was  able  to  converse  quite 
rationally  on  many  subjects,  but  was  greatly  disturbed  by  imagining 
that  men  visited  her  at  night  for  unlawful  purposes.  She  also  had 
disease  of  the  uterus.  There  are  a  great  many  ways  in  which  cere- 
bration indicates  that  the  brain  is  influenced  by  the  sexual  organs, 
and  such  derangement  of  thought,  shown  by  abnormal  conversations, 
is  often  valuable  in  pointing  to  disease  of  the  pelvic  organs.  Ob- 
scene or  licentious  mental  expressions  do  not  ahvays  indicate  disease 
of  the  sexual  organs.  The  demoralization  of  the  insane  may  come 
from  previous  bad  habits  and  associations,  or  may  be  developed  by 
the  disease  of  the  nerve  centers  while  the  sexual  organs  are  normal. 
Perverted  thought,  when  cut  off  from  the  control  of  the  reason,  may 
be  made  manifest  while  there  is  no  physical  signs  of  disease  outside 
of  the  brain  itself,  but  when  deranged  emotions  manifested  by  ob- 
scene speech  and  actions  are  observed  in  those  previously  modest  and 
chaste,  they  should  be  taken  as  probable  evidence  of  disease  of  the 
sexual  organs,  and  should  lead  to  further  investigation. 

Physical  exploration  of  the  pelvic  organs  of  insane  women  has 
heretofore  been  beset  with  many  difficulties.  Indeed,  it  has  been 
impossible  to  examine  some  insane  patients.  Persuasion  is  often 
useless,  and  forcible  efforts  to  control  them  ends  mostly  in  defeating 
the.  examiner,  or  injuring  the  patient,  or  both.  The  only  practical 
way  has  been  to  anaesthetize  by  ether,  and  this  has  proved  to  be  very 
unsatisfactory.  It  is  often  a  laborious  task  to  give  ether  or  chloro- 
form to  a  maniac,  to  say  nothing  of  the  danger  and  injurious  after 
effects.     With  such  past  experience,  we  need  not  wonder  that  the 


944:  •  DISEASES   OF  WOMEN. 

practice  of  gynecology  has  found  but  little  favor  among  tliose  hav- 
ing the  care  of  insane  women.  One  has  only  to  witness  the  distress- 
ing scene  enacted  in  forcibly  giving  ether  to  a  maniac,  for  the  pur- 
pose of  treating  a  uterine  disease,  to  be  satisfied  that  the  results  do 
not  justify  the  means. 

To  overcome  all  these  difficulties,  I  use  the  nitrous-oxide  gas  as 
an  anaesthetic,  and  I  am  happy  to  say  that  it  answers  the  purpose 
admirably.  It  acts  quickly  and  pleasantly,  and  has  none  of  the  chok- 
ing effect  which  is  so  distressing  to  those  of  sound  mind,  and  pecul- 
iarly horrifying  to  the  insane. 

The  mode  of  administering  it  is  with  the  apparatus  used  by  the 
dental  surgeons,  to  whom  we  are  greatly  indebted  for  tliese  valuable 
appliances.  In  place  of  using  the  mouth-piece,  a  rubber  cap  is  em- 
ployed, which  fits  over  the  patient's  mouth  and  nose.  The  more 
manageable  cases  are  placed  upon  the  table  while  the  gas  is  admin- 
istered. Refractory  ones  are  placed  in  a  chair,  with  a  back  high 
enough  for  the  head  to  rest  against.  An  attendant  on  each  side 
holds  the  arms ;  the  operator  places  the  cap  over  the  face,  and  holds 
it,  while  a  third  assistant  holds  the  head  steady  between  his  hands 
and  the  back  of  the  chair.  A  few  inspirations  are  usually  sufficient 
to  quiet  the  most  unruly  patient ;  then  the  inhaling  proceeds  quietly 
until  anaesthesia  is  complete. 

By  opening  the  valves  so  as  to  admit  a  portion  of  air,  the  effect 
can  often  be  kept  up  without  producing  the  arrest  of  blood  aeration, 
which  occurs  in  profound  anaesthesia  from  this  agent.  It  is  well,  if 
possible,  to  avoid  this  extreme  anaesthesia,  and  the  lividity  which 
follows,  because  it  changes  the  appearance  of  the  tissues,  and  might 
thereby  interfere  with  minute  examination,  especially  if  the  exam- 
iner is  unaccustomed  to  it. 

So  far  as  the  observations  of  Dr.  Shaw  and  Dr.  Arnold  of  the 
asylum  have  extended,  no  unpleasant  effects  have  followed  the  use 
of  this  agent ;  on  the  contrary,  many  of  the  patients  who  took  it  ap- 
peared to  be  improved  in  their  mental  condition.  One  young  girl, 
who  had  been  many  months  in  the  asylum,  and  who  spent  most  of 
her  time  in  mental  and  physical  inaction,  asked  for  work  to  do,  and 
became  quite  useful  after  having  taking  the  gas  a  few  times.  The 
improvement  could  not  have  come  from  the  treatment  of  her  local 
derangement,  because  she  did  not  improve  in  that  respect.  There 
is  much  reason  for  believing  that  the  nitrous-oxide  gas  is  a  valuable 
tonic  in  cases  of  extreme  debility  of  the  nervous  system.  Drs. 
Barker  and  Blake  related  some  instructive  cases  bearing  upon  this 
subject  in  the  New  York  Obstetrical  Society.    Both  these  gentlemen 


GYNECOLOGY    AS   RELATED   TO   INSANITY   IN   WOMEN.    945 

employed  the  gas  in  such  small  doses  as  not  to  cause  anaesthesia,  and 
the  effect  was  very  satisfactory.  I  heheve  that  further  observation 
will  show  that  like  good  will  follow  in  some  cases  where  it  is  given 
as  an  anaesthetic.  If  that  should  prove  to  be  so  on  further  observa- 
tion, this  agent  will  exercise  a  double  advantage.  As  it  is,  the  use 
of  it  in  the  treatment  of  diseases  of  the  sexual  organs  of  insane 
women,  is  a  contribution  from  gynecology  to  the  management  of 
the  insane  which  promises  to  be  of  great  benefit. 

The  physical  signs  of  disease  vary  but  little  from  those  in  ordi- 
nary cases,  with  a  few  exceptions  which  may  be  mentioned.  The 
absence  of  tenderness  is  almost  always  marked.  Patients  rarely 
complain  of  being  hurt  by  examination  or  treatment.  This  is  so 
marked  as  to  be  noticeable  in  those  who  permit  treatment  without 
taking  an  anaesthetic.  When  the  mental  derangement  has  existed 
for  several  months  or  longer,  and  the  menses  have  been  absent,  the 
vagina  and  cervix  uteri  are  found  to  be  pale  and  anaemic.  The 
appearance  resembles  that  found  in  those  who  have  passed  the 
menopause.  This  does  not  indicate  any  active  disease,  but  simply 
shows  the  inactive  condition  of  the  circulation  and  nutrition.  Con- 
stipation is  so  common  among  insane  women  as  to  make  it  almost 
the  rule  to  find  the  rectum  distended.  This  fact  should  be  borne 
in  mind  so  that  the  bowels  may  be  emptied  before  making  an  ex- 
amination, thereby  disposing  of  one  of  the  chief  obstacles  to  oar 
investigations.  The  diagnosis  of  ovarian  diseases — obscure  at  all 
times — is  most  difficult  among  the  insane.  It  is  well  known  how 
much  dependence  is  placed  upon  the  presence  of  tenderness  on 
pressure  in  ascertaining  the  condition  of  the  ovaries.  Tliis  valuable 
sign  is  lost  when  we  examine  under  an  anaesthetic,  and  even  when 
the  patient  is  conscious,  we  can  not  always  tell  by  her  behavior 
whether  pressure  hurts  or  not.  Still  in  one  case  I  was  able  to 
detect  disease  of  the  right  ovary  by  observing  that  the  organ  was 
enlarged,  prolapsed,  and  tender  on  strong  pressure.  There  was  also 
rigidity  of  the  abdominal  muscles  on  that  side,  which  was  marked 
when  compared  with  the  left  side. 

Regarding  the  diseases  which  occur  among  the  insane  there  is 
little  that  is  peculiar  or  worthy  of  notice.  We  find  the  same  organic 
affections  of  the  uterus  and  ovaries  as  are  met  amono-  rational  beino^s, 
and  while  their  symptoms  are  modified  by  the  state  of  the  nervous 
system,  their  physical  signs  are  the  same.  It  is  possible  that  malig- 
nant disease  of  the  uterus  occurs  more  frequently  among  the  insane. 
There  are  reasons  for  believing  also  that  the  products  of  former 
diseases,  such  as  puerperal  metritis,  pelvic  peritonitis,  and  cellulitis, 
61 


946  DISEASES   OF   WOMEN. 

are  found  more  frequently  in  this  class  of  patients  than  among  sane 
women. 

The  treatment  of  diseases  of  the  reproductive  organs  of  insane 
women  is  based  upon  the  general  principles  which  guide  the  physi- 
cian in  ordinary  practice.  There  are,  however,  circumstances  peculiar 
to  this  class  of  patients  which  must,  of  necessity,  modify  our  treat- 
ment, and  therefore  I  will  mention  some  facts  of  clinical  observa- 
tion which  are  worthy  of  notice.  While  discussing  functional  dis- 
ease, such  as  amenorrhoea,  it  was  claimed  that  constitutional  treat- 
ment alone  was  required  in  such  cases.  That  is  doubtless  true. 
Local  treatment  can  accomplish  very  little  to  relieve  such  conditions, 
either  among  the  insane  or  the  sane.  Persistent  amenorrhoea  seldom 
yields  to  local  treatment,  such  as  stem  galvanic  pessaries,  the  local 
use  of  electricity,  leeching  and  blistering  the  uterus,  and  the  diffi- 
culties in  the  way  of  employing  such  means  among  the  insane, 
practically  exclude  their  use. 

In  the  management  of  cervical  endometritis  it  is  necessary  to  use 
means  that  do  not  require  frequent  repetition.  On  that  account  the 
hot-water  douche  (a  most  valuable  remedy)  can  not  be  used,  because 
these  patients  will  not  permit  the  nurse  to  treat  them,  nor  will  they 
use  it  themselves,  except  in  rare  cases.  There  is  the  same  objection 
to  the  use  of  the  cotton-and-glycerine  tampon,  which  requires  to  be 
renewed  every  day.  In  such  cases  I  have  used  with  advantage  an 
application  of  equal  parts  of  tinct.  iodine  and  carbolic  acid  once  a 
week.  This  is  a  sedative,  and  also  changes  the  abnormal  action  of 
the  mucous  membrane,  causing  a  diminution  of  the  leucorrhoeal 
discharge,  the  erosion  of  the  surface  disappearing,  not  by  being 
replaced  by  cicatricial  tissue,  but  by  the  restoration  of  normal  epi- 
thelium. When  improvement  begins  it  is  well  to  lessen  the  pro- 
portional quantity  of  the  acid. 

Yaginitis  is  also  a  difficult  disease  to  treat  among  insane  women, 
owing  to  the  same  objections  to  the  vaginal  douche.  Little  progress 
can  be  made  in  the  management  of  this  affection  without  thorough 
cleanliness,  and  that  is  difficult  to  obtain  in  insane  patients.  In 
fact  vaginitis  and  vulvitis  occur  oftener  in  this  class  of  patients 
than  in  those  of  sound  mind,  owing  apparently  to  want  of  care 
in  keeping  the  parts  clean.  Some  of  the  most  marked  cases  of 
purulent  vaginitis  that  have  ever  come  under  my  observation  were 
among  my  patients  in  the  asylum. 

The  treatment  adopted  in  these  cases  consisted  in  first  cleansing 
the  mucous  membrane  thoroughly  with  a  sponge,  and  then  applying 
a  mild  solution  of  nitrate  of  silver,  or  sulphate  of  zinc  with  fluid  ext. 


GYNECOLOGY   AS   RELATED   TO   INSANITY   IN   WOMEN.   947 

,of  hydrastis  Canadensis  and  water,  and  then  introducing  a  tampon  of 
marine  lint.  This  tampon  is  changed  for  a  new  one  every  two  or 
three  days,  until  the  inflammation  subsides.  The  tampon  is  sufficient 
to  cure  most  cases  of  vaginitis  without  any  other  treatment.  It  sepa- 
rates the  inflamed  surfaces,  and  by  absorbing  the  secretions,  keeps 
the  parts  perfectly  clean.  The  tar  which  it  contains  is  one  of  the 
most  useful  remedies  in  inflammations  of  mucous  membranes,  and 
besides  fulfills  a  modern  demand  in  surgery  in  being  antiseptic. 
This  method  of  treating  vaginitis  has  been  tried  in  general  practice 
and  answers  well,  but  it  is  among  the  insane  where  its  value  is  most 
marked. 

Endometritis  polyposa,  or  fungosa,  with  the  menorrhagia  which 
is  caused  thereby,  is  quite  a  common  affection  among  the  insane, 
judging  from  the  number  of  cases  which  have  come  under  my  own 
observation.  To  meet  the  indications  and  the  circumstances  which 
the  accompanying  insanity  gives  rise  to,  I  have  adopted  with  satis- 
factory results,  the  following  method  of  treatment : 

Having  made  a  positive  diagnosis,  a  small  curette  or  scoop  hav- 
ing a  flexible  stem,  is  carried  into  the  cavity  of  the  uterus,  and  the 
whole  of  the  fungous  material  broken  down  and  removed.  This 
simple  operation  is  often  followed  by  complete  recovery.  Some- 
times the  polypoid  growth  returns  and  a  repetition  of  the  operation 
is  necessary.  In  a  very  few  cases  it  has  returned  again  and  again, 
but  has  finally  yielded  to  the  use  of  bichloride  of  mercury  given  in 
the  usual  doses,  and  the  application  of  tinct.  iodine  and  carbolic 
acid  after  the  use  of  the  curette.  There  is  nothing  new  in  this 
method  of  treating  the  disease  in  question,  except  in  omitting  dila- 
tation of  the  cervix  by  tents  as  a  preliminary.  This  is  entirely 
unnecessary  and  should  be  avoided,  because  it  is  painful  and  dan- 
gerous, while  the  use  of  the  blunt  scoop  is  less  likely  to  give  after- 
trouble  than  any  other  form  of  intra-uterine  treatment  that  I  am 
familiar  with.  The  methods  of  treating  this  affection  given  in  our 
books  are  first  to  dilate,  use  the  curette,  and  finally  use  some  caus- 
tic or  alterative  application  to  the  whole  endometrium.  This  re- 
quires that  the  patient  should  be  confined  to  bed  several  days,  care 
being  taken  to  prevent  the  development  of  inflammation  ;  and  with 
all  there  is  danger.  Such  practice  is  impossible  among  the  insane. 
There  are  few  of  that  class  of  patients  that  can  be  kept  quiet  in  bed 
while  undergoing  such  treatment.  The  same  object  can  be  attained 
without  interrupting  the  patient  in  her  usual  mode  of  life.  I  have 
used  the  curette  in  office-practice  with  as  little  caution  as  I  make 
mild  applications  to  the  cervical  canal,  and  have  so  far  had  no  acci- 


948  DISEASES   OF  WOMEN. 

dents.  In  the  confidence  based  upon  tliat  experience  tlie  treatment 
was  employed  among  the  insane,  and  the  results  have  been  quite 
satisfactory. 

With  regard  to  lacerations  of  the  cei^vix  uteri  in  the  insane,  I 
have  simply  to  say  that  the  evil  that  such  lacerations  give  rise  to  are 
well  enough  known  to  warrant  us  in  declaring  that  any  patient  with 
that  complaint,  whether  sane  or  insane,  has  a  right  to  claim  relief  at 
the  hands  of  the  gynecologist.  The  success  of  the  operation  de 
pends  to  some  extent  upon  the  details  of  after  treatment,  such  as 
rest  in  bed  and  cleanliness.  This  is  difficult  to  obtain  among  insane 
women,  but  in  lieu  of  that  I  have  employed  a  method  of  operating 
which  gives  fair  results,  even  when  the  patient  goes  around  during 
the  healing  process,  to  wit :  the  use  of  silk  sutures  and  the  lint  tam- 
pon in  place  of  the  douche. 

The  advantage  is  that  the  sutures  can  not  wound  the  vagina  like" 
the  ends  of  a  silver-wire  suture,  and  the  tampon  supports  the  uterus 
and  guards  against  putting  a  strain  upon  the  sutures  when  the 
patient  moves  or  sits  up.  This  method  is  well  adapted  to  practice 
among  the  insane.  While  I  would  hesitate  to  operate  in  the  usual 
way  upon  an  insane  patient,  I  have  practiced  the  method  described 
with  marked  success.  A  question  m^ay  be  raised  as  to  the  propriety 
of  leaving  a  silk  suture  in  the  cervix  during  the  time  requisite  for 
healing.  The  constant  heat  and  moisture  to  which  the  suture  is  ex- 
posed, certainly  favor  decomposition  of  the  silk,  and  if  that  should 
occur  the  suture  would  cause  suppuration.  I  have  demonstrated 
that  no  such  results  need  be  feared  when  the  silk  is  properly  pre- 
pared by  immersing  it  for  several  hours  in  a  composition  of  melted 
wax,  salicylic  and  carbolic  acids.  I  have  removed  such  a  suture 
from  the  cervix  that  had  been  there  for  one  year,  two  months  and 
twenty  days.  The  patient  was  operated  upon,  and  when  removing 
the  sutures  after  union  had  taken  place,  I  carelessly  missed  one. 
She  soon  became  pregnant,  and  six  weeks  after  confinement,  she 
called  for  examination  to  ascertain  the  effect  of  delivery  on  the  cer- 
vix, and  then  I  found  the  missing  suture.  It  had  caused  no  great 
trouble,  and  was  in  a  very  good  state  of  preservation. 

The  pelvic  pain  or  neuralgia,  which  arises  from  cicatrices  of  the 
cervix  and  vagina,  is  often  very  annoying,  and  calls  for  treatment. 
Marked  relief  follows  after  dividing  the  bands  of  cicatricial  tissue. 
In  two  insane  cases  I  have  now  in  mind  this  treatment  was  the  only 
means  that  could  easily  be  employed,  and  the  results  were  very  satis- 
factory. One  was  a  case  of  scar  tissue  of  the  cervix  from  the  reck- 
less use  of  nitrate  of  silver ;  the  other  had  a  number  of  cicatricial 


GYNECOLOGY   AS   RELATED  TO  INSANITY   IN   WOMEN.    949 

bands  in  the  vagina  resulting  from  gangrenous  vaginitis  occurring 
after  scarlatina  in  girlhood. 

Displacement  of  the  uterus,  i.  e,  prolaj)SUS  and  versions  can  be 
treated  with  good  results,  excepting  when  there  are  anatomical  or 
functional  imperfections  of  the  peringeum.  The  displaced  uterus 
can  be  readily  restored  and  a  pessary  adjusted  while  the  patient  is 
auEesthethized.  It  is  necessary  to  frequently  examine  such  patients 
while  wearing  pessaries,  because  they  may  suffer  without  complain- 
ing. 

The  most  important  difficulty  is  encountered  in  the  management 
of  displacements  in  those  having  an  imperfect  perinseum.  Pessaries 
or  supports  held  in  place  by  being  fastened  to  the  body  can  not  be 
used,  and  on  that  account  we  are  limited  to  intra-vaginal  pessaries, 
which  require  the  presence  of  the  perinseum.  To  restore  a  lacerated 
peringeum  would  be  easy,  but  to  secure  the  after  treatment  neces- 
sary to  a  good  result  is  often  difficult.  Investigation  of  this  subject 
among  the  insane  has  been  very  limited,  but  I  am  satisfied  that  in 
many  cases  the  restlessness  of  such  patients  would  render  the  use  of 
the  silver  wire  unsatisfactory.  I  believe  that  the  use  of  silk  would 
be  a  great  improvement  in  these  plastic  operations  among  the  insane. 
Attention  is  called  to  this  subject  as  a  field  inviting  experimenta- 
tion. Flexion  of  the  uterus,  in  its  various  forms,  gives  rise  to  much 
suffering  when  the  menstrual  function  continues,  and  dysmenorrhoea 
is  a  common  result.  In  quite  a  number  of  patients  with-  flexion 
there  is  amenorrhosa,  and  in  such  flexion  alone  is  presumed  to  give 
no  trouble.  There  is  no  reason  for  believing  that  a  flexion  unasso- 
ciated  with  any  other  disease  of  the  uterus  would  give  rise  to  dis- 
turbance of  the  brain  or  nervous  system  in  a  patient  who  does  not 
menstruate ;  so  I  have  avoided  local  treatment,  believing  that  noth- 
ing would  be  gained  by  anything  that  could  be  done.  But  when  the 
menses  recur,  and  are  painful,  the  probabilities  are  that  the  flexion 
is-  the  cause  of  the  dysmenorrhoea,  and  it  should  be  relieved  if  possi- 
ble. Knowing  how  difficult  flexions  are  to  cure,  when  the  circum- 
stances are  favorable,  it  need  hardly  be  stated  that  the  treatment  of 
such  deformities  in  the  insane  is  often  very  unsatisfactory.  The 
most  daring  gynecologist  would  hesitate  to  use  a  stem  pessary,  or 
perform  division  of  the  cervix,  in  a  x^atient  who  could  not  be  well 
controlled  during  the  after  treatment.  In  flexion  of  the  cervix  divi- 
sion might  be  practiced  in  patients  not  too  violent  and  uncontroll- 
able. As  a  rule,  however,  the  treatment  in  such  cases  is  limited  to 
subduing  any  excessive  irritability  of  the  uterus,  and  securing  a  suffi- 
cient size  of  the  canal  by  dilatation  or  incision,  if  necessary,  and  in 


950  DISEASES   OF  WOMEN. 

cases  of  forward  flexion  of  the  body,  much  might  be  gained  by 
straightening  the  utenis  and  keeping  it  so,  as  far  as  possible  by 
means  of  Thomas's  anteflexion  pessary,  or  some  similar  instrament. 

There  are  forms  of  dysmenorrhoea  (not  dependent  upon  flexion 
of  the  uterus  or  any  known  mechanical  cause)  that  are  presumed 
to  arise  from  ovarian  disease,  or  some  abnormal  condition  of  the 
nerves  supplying  the  sexual  organs.  In  these  cases  the  local  signs 
are  negative,  and  the  only  true  evidence  of  the  painful  menstrua- 
tion is  the  fact  that  the  insanity  is  aggravated  at  that  time,  and  the 
patient  may  indicate  by  the  position  of  the  body,  and  by  placing  the 
hands  over  the  lower  portion  of  the  abdomen,  that  the  seat  of  suffer- 
ing is  in  the  pelvis.  For  cases  of  this  kind  T  know  of  no  special 
local  treatment  that  is  beneficial.  Fortunately  this  form  of  dys- 
menorrlioea  is  rare  among  the  insane.  The  reason  for  this  is  that 
that  the  tender  and  irritable  uterus  and  ovaries  are  relieved,  in  some 
cases  at  least,  upon  the  appearance  of  insanity. 


Il^DEX, 


Acute  endometritis,  177. 

ovaritis,  457. 
Adeno  carcinoma,  401. 
Affections   resembling  ovarian   neoplasms, 

499. 
After  treatment  of  fistula,  901. 
Albert  Smith  pessary,  .SI 7. 
Alexander's  operation,  331. 
Allantois,  82 
Amenorrhoea,  5 '2. 
Ampere,  869. 

Amputation  of  cervix  uteri,  413. 
Anaesthesia  in  diagnosis,  19. 
Anaesthetics,  mode  of  administration,  19. 
Anatomical  relations  of  bladder  and  urethra, 

618. 
Anatomy  of  bladder,  609. 

cervix,  610. 

coats,  610. 

corpus,  610. 

form,  610. 

fundus,  610. 

glands,  611. 

inter-ureteric  ligament,  612. 

ligaments,  619. 

nervous  supply,  613. 

openings,  612. 

ostium,  urethral,  612, 

position,  610. 

relations  to  urethra,  618. 

sphincter,  vesical,  611. 

trigone,  610, 

ureters,  612. 

vascular  supply,  613. 
of  Fallopian  tubes,  547. 

coats,  547. 

length,  547. 

orifices,  547. 


Anatomy   of   Fallopian  tubes,  relation   to 
uterus  and  broad  Hgaments,  547. 
of  ovary,  438. 

blood-supply,  439. 

length,  439. 

minute  anatomy,  443. 

ovulation,  446. 

relation  to  broad  ligament,  439. 

thickness,  439. 

weight,  439. 

width,  439. 
of  pudendum,  77. 

clitoris,  77. 

glands,  77. 

labia  majora  and  minora,  76. 

hymen,  76. 

vestibule,  77. 
of  urethra,  613. 

coats,  614. 

diameter,  613. 

length,  613. 

meatus  urinarius,  616. 

relation  to  bladder,  618. 

Skene's  glands,  614. 

sphincter,  urethral,  617. 
of  uterus,  171. 

arbor-vitge,  174. 

body,  171. 

cavity,  172, 

cervix,  171. 

fundus,  171. 

length,  171. 

mucous  membrane  of  cavity,  172. 

mucous   membrane   of  cervical  canal, 
174. 

Nabothian  glands,  174. 

OS  externum,  172. 

OS  internum,  172. 


952 


DISEASES   OF  WOMEN". 


Anatomy  of  uterus,  peritoneal  covering,  172. 
utricular  glands,  173. 
walls,  172. 
width,  171. 
of  vagina,  99. 
coats,  100. 
connection  with  cervix  uteri  and  pelvic 

floor,  99. 
length  of  walls,  99. 
orificium,  80. 
Anteflexion  of  the  uterus,  57. 
acquired,  57. 
causation,  61. 
congenital,  57. 
illustrative  cases,  69. 
of  body,  58. 
of  cervix,  57. 
of  cervix  and  body,  58. 
pathology,  58. 
physical  signs,  60. 
symptomatology,  59. 
treatment,  64. 

Elliott's  adjuster,  68. 
pessaries,  68. 
Hewitt's,  68. 
Thomas's,  68. 
sui'gical  methods,  64. 
Anterior-labial  hernia,  91. 
Antero-posterior  laceration  of  cervix  uteri, 

243. 
Anteversion,  286. 

pessaries,  Thomas's,  68. 
Antiseptic  dressings,  136. 
Anus,  atresia  of,  82. 
Apostoli's  electrodes,  375. 
Arbor-vitse  uterina,  174. 
Areolar  hyperplasia  of  uterus,  220. 
Arrest  of  haemorrhage,  527. 
Art  of  investigation,  1. 
Atlee,  W.  L.,  M.  D.,  313. 
Atresia  of  anus,  82. 
of  bladder,  816. 
of  vagina,  101. 
of  vulva,  82. 
Atrophy  of  muscles  of  pelvic  floor,  160. 
of  muscular  tissue  of  vaginal  walls  from 

abuse  of  pessaries,  335. 
of  uterine  walls,  332. 

from  senile  malnutrition,  124. 

Baker's  operation  for  amputation  of  cervix 
uteri,  414. 


Benign  growths,  804. 

mucous  polypus,  804. 
myxoma,  804. 
papilloma,  406. 
polypoid  hypertrophy,  804. 
Bilateral  laceration  of  cervix  uteri,  245,  347. 
complicated,  253. 
incomplete,  256. 
uncomplicated,  252. 
with  thickening  of  everted  lips,  244. 
with  unequal  division  of  cervix,  244. 
Bimanual  method  of  examination,  9. 
Bladder,  anatomy  of,  609. 
development  of,  609. 
diseases,  653. 
distended,  498. 
dislocation  of,  760. 
Bleeding  disease  of  uterus,  356. 
Broad  ligament,  282. 
Bulbi  vestibuli,  78,  80. 
Byrne's  battery,  372. 

Calculus,  780. 
Cancer,  398. 
juice,  399. 
of  cervix,  398. 
of  body  of  uterus,  417. 

causing  vulvitis,  84. 

diagnosis,  418. 

etiology,  418. 

pathology,  417. 

physical  signs,  418. 

prognosis,  418. 

symptomatology,  418. 

treatment,  418. 
Carcinoma,  111,  473. 
Carunculse  myrtiformes,  81. 
Catheter,  use  of,  137. 

Cauliflower  excrescence  of  cervix  uteri,  401. 
Caustics  in  treatment  of  cancer  of  uterus, 

411. 
Cautery  clamp,  513. 

Paquelin's,  111. 
Cervical  canal  of  uterus,  173. 
Cervical  endometritis,  179. 

exanthematous,  176. 

gonorrhoeal,  176. 

in  an  imparous  woman,  196. 

in  an  imperfectly  developed  uterus,  197. 

puerperal,  176. 

with  hyperplasia  of  mucous  membrane, 
191. 


INDEX. 


953 


Cervical  endometritis  with  stenosis  and  cys- 
tic degeneration,  192. 
Cervix  uteri,  hypertrophic  elongation  of,  124. 
hypertrophy  of,  343. 
laceration  of,  from  parturition,  242. 
operation  for  restoration  of,  249. 
Chlorosis,  44. 
Chronic  corporeal  endometritis,  212. 
cystitis,  7 16. 
endometritis,  IVS. 
Chronic  inversion  of  uterus,  2*73. 

mistaken  for  fibrous  polypus,  269. 
ovaritis,  454. 
Cicatrices  of  cervix  uteri  and  vagina,  259. 
causation,  259. 
complications,  262. 
illustrative  cases,  262. 
symptomatology,  259. 
treatment,  261. 
Clamp,  heemorrhoid,  151. 
Classification  of  neoplasms  of  ovary,  473. 
Clitoris,  76,  82. 
Cloaca,  82. 
Coccyodynia,  16  V. 
causation,  168.' 
illustrative  case,  169. 
pathology,  167. 
physical  signs,  168. 
prognosis,  168 
symptomatology,  167. 
treatment,  168. 
Nott's,  168. 
Simpson's,  168. 
Coccyx,  removal  of,  170. 
Colloid  cancer,  400. 
Complex  cystoma  of  ovary,  476. 
Compound  cyst  of  ovary,  474. 
Concave  mirror,  18. 
Condyloma,  406. 
Constriction  at  external  os  uteri,  68. 

at  internal  os,  68. 
Contents  of  ovarian  cysts,  480. 
Corporeal  endometritis,  202. 
Corpus  clitoridis,  77. 

Courty's  method  of  restoring  inverted  ute- 
rus, 274. 
Crescentic  laceration  of  cervix  uteri,  247. 
Croupous  cystitis,  756. 
Cup  pessary  causing  vulvitis  and  ulceration, 

339. 
Curette,  21,  362. 
Curved  scissors,  Emmet's,  138. 


Cusco's  speculum,  14. 
Cylindrical-celled  epithelioma,  401. 
Cystic  degeneration  of  cervix  uteri,  181. 
Cystitis,  703,  710. 

acute,  711. 

causation,  730. 

chronic,  716. 

croupous,  756. 

diagnosis,  758. 

diphtheritic,  710. 

epi-cystitis,  710. 

gonorrhoeal,  710. 

pathology,  716. 

prognosis,  758. 

symptomatology,  720. 

treatment,  737,  759. 
Cysto-carcinoma,  473. 
Cysto-fibroma,  477. 
Cysto-sarcoma,  473. 
Cysts  of  vagina,  109. 

Dawson's  battery,  372. 
Dermoid  cysts,  477". 
Development  of  bladder,  620. 

of  Fallopian  tubes,  22. 

of  Graafian  follicles,  445. 

of  ovaries,  442. 

of  sexual  organs,  22. 

of  urethra,  620. 

of  urinary  organs,  22. 

of  uterus — primary,  22. 
secondary,  24. 

of  vagina,  22. 
Diagnosis,  differential,  in  ascites  and  ovarian 
cysts,  504. 

in  encysted  dropsy  and  ovarian  cysts,  504. 

in  ovarian  and  parovarian  cysts,  503. 

in  pregnancy,  501. 

in  uterine  fibroma,  502. 
Dilatation  of  cervix  uteri,  69. 

of  urethra,  9,  849. 
Dilators:  urethral,  17. 

uterine,  17. 

Palmer's,  11. 

Hanks's,  17. 
Diseases  of  Fallopian  tubes,  359,  547. 

of  ovaries,  454. 

of  pudendum,  84. 

of  urethral  glands,  879. 

of  urethra,  818. 

of  urinary  organs,  609. 

of  uterus,  171. 


954 


DISEASES   OF   WOMEN". 


Diseases  of  vagina,  99. 
Dislocation  of  urethra,  861. 
Displacements  of  ovaries,  466. 

of  uterus,  2S6. 
Double  vagina,  100. 
Dragging    of    pedicle    in    ovarian    tumor, 

485. 
Drainage  in  ovarian  tumor,  526. 
Dressings,  136. 
Ducts,  Mliller's,  22. 
Dudley's  method  of  treating  fistula  in  ano, 

165. 
Dupuvtren's  operation  for  atresia,  103. 
Dysmenorrhcua :  inflammatory,  204. 

membranous,  229. 

neurotic,  59. 

obstructive,  59. 

ovarian,  456. 

Eeraseur,  362,  413. 
Electrolysis :  ampere,  369. 
anions,  371. 
battery,  371. 

Byrne's,  372. 

chloride  of  silver,  372. 

Dawson's,  372. 

Law,  372. 

Leclanche,  372. 

Piffard's,  372. 
cations,  371. 
circuit,  367. 
conductors,  368. 
current,  367. 
electrodes,  368. 
electrolytic,  371. 
electro-motive  force,  368. 
electro-negative  elements,  371. 
electro-positive  elements,  371. 
faradism,  367. 
galvanism,  367. 

in  the  treatment  of  fibroids,  394. 
law  of  currents,  369. 
negative  elements,  367. 
negative  pole,  367. 
non-conductors,  368. 
ohm,  369. 
Ohm's  law,  369. 
positive  elements,  367. 
positive  pole,  367. 
static  electricity,  367. 
volt,  369. 
Elliott's  uterine  adjuster,  67. 


Elongation,  hypertrophic,  of   cervix    uteri, 

347. 
Encysted  dropsy  of  the  peritonaeum,  498. 
Endometritis,  17S. 
Enlargement  and  cysts  of  the  liver,  spleen, 

and  kidneys,  49S. 
Epithelioma,  microscopical  appearances,  402. 
of  the  cervix  uteri,  401. 
pathology,  401. 
pavement-celled,  401. 
physical  signs,  404. 
I'odent  ulcer,  401. 
secondary  invasion,  402. 
symptomatology,  402. 
treatment,  408. 
amputation,  413. 
astringent  injections,  408. 
Baker's  operation,  414. 
cannabis  Indica,  409. 
caustics,  411. 
chromic  acid,  409. 
cocaine,  409. 
constitutional,  408. 
curette,  412. 
diet,  409. 
eeraseur,  413. 
galvano-cautery,  413. 
hydrate  of  chloral,  409. 
hyoscyamus,  409. 
iodoform,  409. 
local,  408. 
milk  of  aveloz,  410. 
nitric  acid,  409. 

Paquelin's  thermo-cautery,  412. 
rest,  408. 

Schroeder's  operation,  413. 
Erosions  of  cervix  uteri,  406. 
Eruptions  of  vulva,  97. 
diphtheria,  98. 
eczema,  97. 
acute,  97. 
chronic,  97. 
treatment,  97. 
erysipelas,  97. 

treatment,  98. 
gangrene,  98. 
causation,  98. 
prognosis,  98. 
treatment,  98. 
herpes,  97. 
noma,  98. 
prurigo,  97. 


INDEX. 


955 


Eruptions  of  vulva,  prurigo,  treatment,  97. 
Erythema,  84. 

Examination  of  patients,  8,  1 0. 
ansBsthesia,  19. 

method  of  administration,  19. 
aspirator,  17. 
classification  of  facts,  4. 
concave  mirror,  18. 
curette,  16. 

Recamier's,  16. 

Skene's,  16. 
dilators,  17. 

Hanks's,  17. 

Palmer's,  17. 
examining  table,  8. 
history  of  reproduction,  7. 
inspection,  3. 

investigation  of  diseases  of   sexual   sys- 
tem, 5. 
microscope,  18. 
palpation,  10. 
palpation  and  percussion  conjoined,  10. 

diametrical  method,  10. 

fluctuation,  10. 

interrupted  pressure,  10. 

peripheral  method,  10. 
percussion,  10. 
physical  signs,  7. 
position,  11. 

dorsal,  8. 

Sims's,  11. 
resume  of  methods,  19. 
sound  and  probe,  14. 

elastic,  15. 

Jenks's,  15. 

Simpson's,  14. 

Sims's,  15. 
sound  and  palpation  combined,  16. 
speculum,  11. 

Cusco's  bivalve,  11. 

Sims's,  11. 

introduction,  13. 
movements,  13. 
symptomatology,  6. 
tents,  17. 

compressed  sponge,  17. 

sea-tangle,  17. 

tupelo,  17. 
touch,  8. 

bimanual,  9. 

by  dilatation  of  urethra,  9. 
rectal,  10. 


Examination  touch,  single,  8. 

Simon's  method,  9. 

vesico-rectal,  10. 

vesico- vaginal,  10. 
Excision  of  uterus,  415. 
Excrcmentitious  plethora,  431. 
External  genital  organs,  77. 

Facts,  classification  of,  4. 
Fallopian  tubes,  547. 
anatomy,  547. 
anomalies,  547. 
development,  22,  547. 
diseases,  547. 
Fecal  impaction,  498. 
Fibroma  of  the  ovary,  478. 
of  uterus,  848. 
synonyms,  348. 

bleeding  disease  of  the  uterus  (Dun- 
can), 348. 
fibroid,  348. 
fibrous  myoma,  348. 
fibro-myoma,  348. 
hysteroma,  348. 
varieties,  349. 

conglomerate,  350. 
interstitial,  349. 
multiple,  350. 
single,  350. 
submucous,  349. 
subperitoneal,  349 
within  folds  of  broad  ligament,  349. 
calcareous  degeneration,  352. 
causation,  359. 
clinical  history,  351. 
density,  351. 
diagnosis,  358. 

effects  of,  upon  the  uterus,  353. 
fatty  transformation,  352. 
osseous  degeneration,  352. 
physical  signs,  357. 
prognosis,  360. 
symptomatology,  355. 
treatment,  361. 
medicinal,  361. 
ergot,  361. 
.     surgical,  362. 
curette,  362. 
ecraseur,  362. 
electrolysis,  366. 
hysterectomy,  365. 
Keith's  views,  365. 


956 


DISEASES    OF   WOMEN. 


Fibroma  of  uterus,  surgical  treatment,  elec- 
trolysis, 366. 

ovariotomy,  365. 
Fibrous  polypi,  406. 
Fistula  in  ano,  162. 
operation,  165. 

Dudley's,  166. 
treatment,  162. 
new  method,  166. 
vesico-vaginal,  897. 
Flexions  of  the  uterus,  54. 
causation,  61. 
diagnosis,  61. 
pathology,  5S. 
physical  signs,  60. 
symptomatology,  59. 
treatment,  64. 
varieties,  57. 
Fluctuation,  10. 
Foreign  bodies  in  bladder,  777. 
calculus,  780. 
causation,  781. 
diagnosis,  780. 
prognosis,  781. 
symptomatology,  780. 
treatment,  782. 
in  urethra,  875. 
Fossa  navicularis,  78. 
Fourchette,  76. 
Frsenulum  vulvse,  76. 
Frequent  urination   associated  with   slight 

anteversion  of  bladder,  338. 
Freund's  operation  for  removal  of  uterus, 

415. 
Functional  diseases  of  bladder,  653. 

derangements  of  function  in  which  there 
is  no  recognizable  organic  lesion,  653. 
causation,  660. 
diagnosis,  659. 
illustrative  cases,  663. 
neurosis,  658. 

due  to  disorders  of  sexual  functions, 

655. 
due  to  hysteria,  654. 
due  to  malaria,  656. 
due  to  ovarian  affections,  657. 
prognosis,  659. 
symptomatology,  658. 
treatment,  660. 
derangements  of  function  due  to  diseases 
of  the  nutritive  and  nervous  systems, 
674. 


Functional  diseases  of  bladder,  paralysis,  674. 

causation,  677. 

diagnosis,  676. 

enuresis  nocturna,  680. 

prognosis,  677. 

symptomatology,  675. 

treatment,  677. 
incontinence  of  urine,  680. 

prognosis,  681. 

treatment,  681. 

illustrative  cases.  684. 
derangements  of  function  due  to  abnor- 
mal condition  of  urine,  685. 

causation,  687. 

diagnosis,  687. 

illustrative  cases,  689. 

prognosis,  687. 

symptomatology,  687. 

treatment,  687. 
derangement  of  function  due  to  affections 

of  the  pelvic  organs  other  than  the 

bladder,  691. 
Functional  diseases  of  urethra,  818. 
Function  of  bladder,  647. 
Functions  of  uterus,  175. 
gestation,  176. 
impregnation,  176. 
menstruation,  30. 

Galvano-cautery,  413. 
Ganglionic  dysesthesia,  429. 
Genital  cleft,  82. 

eminence,  82. 
Glands  of  Naboth,  174. 
Glandulse  vestibulares  minores,  78. 

majores,  78. 
Gonorrhoea,  84. 
Graduated  sounds,  69. 
Granular  erosion,  825. 
Gynecology  as  related  to  insanity  in  women, 

929. 

Hsematosalpinx,  551. 

etiology,  552. 

symptomatology,  552. 

treatment,  552. 
HaBmorrhage,  arrest  of,  527. 
of  the  bladder,  705. 

causation,  705. 

illustrative  cases,  709. 

symptomatology,  705, 

treatment,  707. 
secondary,  134. 


INDEX. 


95Y 


Ilicmorrlioid  clamp,  151. 
Ilavvk-bill  scissors,  249. 
Ilcnnaplirodilism,  82. 
Hernia  of  the  pudendum,  91. 

anterior  labial,  91. 

diagnosis,  92. 

posterior  labial,  91.  , 

treatment,  92. 
History  of  reproduction,  1. 
Hot  w^ter  in  controlling  hyemorrhago,  134. 
Hydatid.'^  in  the  bladder,  779. 
Hydrate  of  chloral,  409. 
Hydrocele  of  round  ligament,  93. 

treatment,  93. 
Hydronephrosis,  400. 
Hydrosalpinx,  549. 
Hymen,  76,  78,  81. 
Hyoscyamus,  409. 
Ilypenemia  of  the  bladder,  703. 

causation,  704. 

diagnosis,  704. 

symptomatology,  704. 

treatment,  705. 
Hyperaesthesia,  109. 
of  vulva,  93, 

causation,  94. 

treatment,  94. 
Hyperplasia  of  bladder,  814. 

diagnosis,  815t 

treatment,  815. 

symptomatology,  815. 
Hypertrophic  elongation,  347. 

of  the  cervix  uteri,  124. 
Hypertrophy  of  the  cervix  uteri,  343o 

causation,  345. 

pathology,  343. 

physical  signs,  344. 

prognosis,  345. 

symptomatology,  343. 

treatment,  345. 
Hypospadias,  82. 
Hysterectomy,  365. 
Keith's  cases,  389. 

Illustrative  cases  of  abuse  of  pessaries,  334- 
341. 
bladder:  atrophy,  817. 
cystitis,  752-756. 
derangements,  691. 
dislocations,  762. 
displacements,  771. 
functional  diseases,  663-671. 


Illustrative  cases,  bladder,  foreign  bodies  in, 
783-791. 

irritation  of,  689. 

malformations  of,  636-646. 

paralysis  of,  684. 

prolapsus  of,  769. 

rupture  of,  797-803. 
cellulitis,  pelvic,  564-578. 
coccyx,  rem.oval  of,  169. 
cervix  uteri,  cicatrices  of,  262-265. 

lacerations  of,  252-257. 
endometritis,  cervical,  189-200. 

corporeal,  209-212. 
fistulse  in  ano,  66. 

loss  of  base  of  bladder  and  urethra, 
917-928. 

urethral,  914-916. 

vesico-vaginal,  901-908. 

with  stricture  of  vagina,  911. 
membranous  dysmenorrhoea,  237-240. 
menopause,  425-435. 
menstrual   derangements   caused   by  ar- 
rested growth  of  uterus,  41. 

chlorosis,  44-46. 

deranged  innervation,  49-53. 

deranged  conditions  of  life,  47. 

malformations  of  uterus,  32  38. 

phlegmatic  temperament,  50. 
ovarian  neoplasms,  530-546. 
pelvic  htematocele,  603-608. 
pelvic  peritonitis,  587-595. 
pelvic  floor,  atrophy  of  muscles  of,  160. 

injuries  of,  149,  159. 

rigidity  of  muscles  of,  161. 
pudendal  ha^matocelc,  91. 
urethra :  dislocation,  864. 

functional  diseases  of,  819. 

granular  erosion,  826. 

gonorrhoeal  inflammation,  887. 

organic  disease  of,  824. 

stricture  of,  872. 
urethral  glands,  gonorrho-al  inflammation 
of,  890. 

tuberculosis  of,  889. 
uterus,  anteflexion  of,  69-73. 

fibroma  of,  377-396. 

inversion  of,  272,  273. 

retroversion  of,  324-327. 

retroflexion  of,  328. 

sclerosis  of,  223-228. 
Imperforate  vagina,  101. 
hymen,  53. 


958 


DISEASES   OF   WOMEN". 


Incontinence  of  rectum,  119. 

of  urine,  680. 
Infantile  uterus,  23. 
Inflammation  of  bladder,  703. 
of  ovary,  454. 

acute  ovaritis,  457. 

causation,  461. 

diagnosis,  460. 

pathology,  458. 

physical  signs,  459. 

prognosis,  460. 

symptomatology,  459. 

treatment,  461. 
chronic  ovaritis,  461. 

causation,  464. 

pathology,  461. 

physical  signs,  464. 

prognosis,  464. 

symptomatology,  463. 

treatment,  465. 
hypersemia,  454. 

causation,  457. 

pathology,  464. 

physical  signs,  456. 

prognosis,  457. 

symptomatology,  455. 

treatment,  457. 
of  urethra,  821. 
of  vagina,  105. 
acute,  105. 
chronic,  105. 
gonorrhoeal,  105. 
erythematous,  105. 
erysipelatous,  105. 
gangrenous,  102. 
of  vulvo-vaginal  glands,  85. 
physical  signs,  85. 
prognosis,  86. 
symptomatology,  85. 
treatment,  86. 
Inflammatory  affections  of  uterus,  176. 
endometritis,  177. 
acute  corporeal,  177. 

causation,  178. 

prognosis,  178. 

treatment,  178. 
chronic,  178. 
cervical,  179. 

causation,  184. 

cystic  degeneration,  181. 

physical  signs,  184. 

prognosis,  185. 


Inflammatory  affections  of  uterus,  cervical, 
pathology,  179. 

symptomatology,  183. 
treatment,  185. 
constitutional,  185. 
local,  186. 
Inguinal  labial  hernia,  91. 
Injuries  of  pelvic  organs,  334. 
pelvic  floor,  112. 
posterior  wall  of  vagina,  337. 
Instruments  used  in  ovariotomy,  519. 
Interrupted  pressure,  10. 
Intra-uterine  ligament,  612. 

stem,  69. 
Inversion  of  uterus,  266. 
causation,  270. 
chronic,  273. 
diagnosis,  269. 
prognosis,  270. 
physical  signs,  267. 
symptomatology,  266. 
treatment,  273. 

methods  of  reduction,  274. 
Barren,  274. 
Noeggerath,  274. 
Thomas,  274. 
of  bladder,  774. 
[schio-perineal  ligament,  114. 
Japanese  ligature,  134. 

Knee-chest  position,  323. 

Labia  majora,  76. 

minora,  76. 
Lacerations, 

cervix  uteri,  242. 
causation,  246. 
consequences,  242. 
frequency,  242. 
importance,  242. 
treatment,  248. 

operation,  249. 
varieties,  243. 

antero-posterior,  245. 
incomplete,  245. 
lateral,  243,  215. 
multiple,  245. 
levator-ani  muscle,  117-122. 
perinseura,  115-118. 
through  sphincter-ani  muscle,  120. 
Laparo-salpingotomy,  550. 
Lateral  displacements  of  bladder,  764. 


INDEX. 


959 


Law  battery,  372. 

Leclanche  battery,  372. 

Length  of  vagina,  91. 

Lesions  of  formation  of  ovary,  453. 

absent,  453. 

rudimentary,  453. 

supernumerary,  453. 
Levator-ani  muscle,  causes  of  injuries  to, 

127. 
Ligature,  Japanese,  134. 
Loss  of  the  whole  base  of  the  bladder  and 
urethra,  917. 

illustrative  cases,  917. 

Malformations  of  bladder,  627. 
ana-spadias,  628. 
double  bladder,  628. 
diagnosis,  636. 
epi-spadias,  628. 
etiology,  629. 
eversio  vesicae,  628. 
extrophia  per  urachum,  628. 
extropia  vesicae,  628. 
extroversion,  636. 
fissure,  627. 

fistula-vesico-umbilicalis,  627. 
inversio  vesicse  cum  prolapsu  per  fissu- 

ram,  628. 
prognosis,  636. 
treatment,  636 
of  uterus,  25. 
absence,  27. 
at  puberty,  25. 
during  embryonic  life,  25. 
illustrative  cases,  28. 
uterus  bipartis,  26. 

bicornis,  26. 

bifundalis  unicollis,  26. 

duplex,  26. 

hypertrophy,  25. 

rudimentary,  27,  30. 

unicornis,  26. 
of  urethra,  622. 

atresia  urethrge,  623. 
defectus  urethrte  totalis,  622. 
defectus  urethrse  externus,  622. 
defectus  urethrge  internus,  623. 
diagnosis,  625. 
double  urethra,  624. 
hypospadias,  623. 
symptomatology,  624. 
treatment,  626. 


Malformations  of  vagina,  100. 
atresia,  101. 
acquired,  101. 
causation,  103. 
complete,  101. 
congenital,  101. 
illustrative  cases,  101. 
partial,  101. 
physical  signs,  102. 
symptomatology,  102. 
treatment,  103. 
Dupuytren's  operation,  103. 
Porteau's  trocar,  105. 
Sims's  dilator,  104. 
double  vagina,  100. 
imperforate  hymen,  100. 
imperforate  vagina,  101. 
perpetuation  of  septum,  100. 
prognosis,  103. 
Malignant  disease  of  uterus,  398. 
cancer,  398. 

cancer  of  cervix  uteri,  398. 
cancer-juice,  399. 
colloid,  400. 
encephaloid,  399. 
epithelioma,  399. 
melanotic,  399. 
pathology,  399. 
pathological  effects,  400. 
hydronephrosis,  400. 
rectitis,  400. 

vesico-vaginal  fistulse,  400. 
scirrhus,  399. 
definition,  398. 
sarcoma,  398. 
Mature  uterus,  24. 
Meatus  urinarius,  78. 
Median   laceration  of   perinseum   down    to 

sphincter  ani,  145. 
Medullary  cancer,  405. 
Membranous  dysmenorrhoea,  229. 
causation,  233. 
illustrative  cases,  237. 
membrane  of,  232. 
pathology,  229. 
physical  signs,  232. 
symptomatology,  231. 
treatment,  235. 

Barker's,  Dr.  Fordyce,  case,  240. 
Menopause,  422. 

illustrative  cases,  425. 
natural  history  of,  422. 


960 


DISEASES   OF   WOMEN. 


Menopause,  symptomatology,  423. 

treatment,  424. 
Menstruation,  30. 

composition  of  menstrual  flow,  31. 

derangement    from    arrest    of    develop- 
ment, 30. 
illustrative  cases,  32. 

derangement  from  causes  independent  of 
sexual  organs,  46. 
illustrative  cases,  49. 

laws  of,  31. 

premature,  from  deranged   condition   of 
life  and  delayed  innervation,  47. 

methods  of  observation,  1. 
Methods    of    exploration   of    bladder    and 
urethra,  694. 

cystoscope,  69*7. 

dilatation  of  urethra,  699. 

examination  of  urine,  694. 

incision  into  the  bladder,  701. 

list  of  instruments,  7C  2. 

Napier's  probe,  699. 

Simon's  method,  699. 

Skene's  bivalve  urethral  speculum,  700. 

Skene's  endoscope,  695. 

touch,  694. 

applying  electric  current,  375. 
Metritis,  176. 

acute,  176. 

chronic,  176. 
Microscopic  contents  of  ovarian  cysts,  481. 
Microscope  in  diagnosis,  18. 
ililliamperemeter,  374. 
Milk  of  aveloz,  410. 
Minute  anatomy  of  ovary,  443. 
Mirror,  concave,  18. 
Mons  veneris,  76. 
Mucous  membrane,  173. 

glands,  78. 
Miiller's  ducts,  22. 

filaments,  22. 
Multilocular  cyst,  474. 
Myoma,  110. 

Naboth,  glands  of,  174. 
Needles,  Emmet's,  898. 

Keith's,  520. 

Peaslee's,  129. 

Skene's,  250. 
Needle  forceps,  141,  250. 
Neoplasms  of  bladder,  804. 
benign,  804. 


Neoplasms  of  bladder,  benign,  fibroma,  804. 

myo-fibroma,  804. 

myoma,  804. 

myxoma,  804. 

tubercle,  811. 
malignant,  804. 

encephaloid,  804. 

epithelioma,  804,  812. 

sarcoma,  804. 

scirrhus,  804. 
causation,  809. 
diagnosis,  808. 
pathology,  804. 
symptomatology,  806. 
treatment,  809. 
of  Fallopian  tubes,  548. 
carcinoma,  548. 
cystoma,  548. 
fibroma,  548. 
lipoma,  548. 
Morgagni's  hydatid,  548. 
myoma,  548. 
papilloma,  548. 
sarcoma,  548. 
tubercle,  548. 
of  ovary,  473. 

adenoid  cystoma,  473. 
carcinoma,  473. 
cystic  tumors,  473. 
cysto-carcinoma,  473. 

fibroma,  473. 

sarcoma,  473. 
dermoid  cystoma,  473. 
follicular  cyst,  473. 
fibrous  cyst,  473. 
multiple  cystoma,  473. 
multilocular  cystoma,  473. 
multiple  follicular  cystoma,  473. 
papillary  cystoma,  476. 
sarcoma,  473. 

simple  follicular  cystoma,  473. 
simple  unilocular  cystoma,  473. 
of  urethra,  835. 
-   areolar,  837. 
compound,  838. 
epithelial,  838. 
glandular,  836. 
papillary,  836. 
vascular,  837. 
of  vagina,  109. 
carcinoma.  111. 
cysts,  109. 


INDEX. 


961 


Neoplasms  of  vagina,  fibroma,  110. 
'        fibromyoma,  110. 

myoma,  110. 

sarcoma,  HI, 
Neurosis,  654. 

Nitrate  of  silver,  long  continued  use  of,  193. 
Normal  menopause,  425. 
Nymphse,  76. 

Observation,  method  of,  1. 
Oophorectomy,  509. 
Orificium  vaginje,  80. 
Ovarian  cysts  : 
causation,  482. 
complex  cystoma,  476. 
compound  cysts,  474. 
complications,  483. 

cystitis,  486. 

dragging  of  pedicle,  485. 

perforation,  486. 

rupture  of  cyst,  485. 
contents  of  cysts,  480. 
cyst-wall,  478. 
cysto-fibroma,  478. 
dermoid  cysts,  477. 
diagnosis,  491,  497. 

ascites,  499. 

cyst  of  broad  ligament,  499. 

distended  bladder,  498. 

encysted  dropsy  of  peritonaeum,  498. 

enlargement  and  cysts  of  liver,  spleen, 
and  kidneys,  498. 

parovarian  cyst,  499. 

summary  of  facts  in  differential  diag- 
nosis, 581. 

uterine   fibroids   and    fibro-cysts,  497, 
500. 
fibroma  of  ovary,  478. 
glandular  cell  of  Drysdale,  482. 
multilocular  cysts,  474. 
microscopia  of  contents,  481. 
ovarian  granular  cell  (Drysdale),  482. 
papillary  cysts,  476. 
pathology,  479. 
physical  signs,  490. 
physical  signs  in  second  stage,  493. 
prognosis,  506. 
simple  cysts,  474. 
symptomatology,  488. 
treatment,  509. 

ovariotomy,  509. 
Ovarian  neoplasms,  501. 


Ovarian  hyperaemia,  454, 
Ovaries,  anatomy  of,  438. 
displacements,  466. 
prolapsus,  454. 
Ovario-uterine  neuralgia,  434. 
Ovariotomy,  509. 
after-treatment,  528, 
anaesthesia,  518. 
antisepsis,  514. 
arrest  of  haemorrhage,  527. 
assistants,  521. 

duties  of,  521. 

positions  of,  521. 
cautery  clamp,  515. 
complications,  524. 
drainage,  515,  526. 

emptying  cysts  in  complicated  cases,  525, 
general  considerations,  510. 
illustrative  cases,  580,  543. 
immediate  preparation  of  patient,  518. 
Keith's  cases,  543. 

list  of  instruments  and  appliances  usually 
needed,  519. 

fenestrated  forceps,  519. 

Keith's  compression-forceps,  519. 

Keith's  ligature-forceps,  520. 

Keith's  needles,  519. 

vulcellum  forceps,  519. 
list  of  instruments  that  may  be  needed, 
520. 

Baker  Brown's  clamp,  520. 

cautery  clamp,  520. 

cautery  irons,  520. 

counter-pressure  instrument,  520. 

drainage-tubes,  520. 
operating-table,  518. 
pedicle,  management  of,  515. 
removal  of  uterine  appendages,  509. 
steps  of  operation,  522. 

cleansing  abdominal  cavity,  522. 

closing  abdominal  wall,  522. 

dressing  abdominal  wound,  522. 

examining  other  ovary,  522. 

exploring  for  adhesions,  522. 

making  incision  in  abdominal  wall,  522. 

placing  patient  in  bed,  522. 

removing  tumor,  522. 

tapping  cyst,  522. 

treating  adhesions,  522. 

treating  pedicle,  523. 

treatment  of  suppurating  cysts,  522, 
Ovaritis,  acute,  454,  457. 


62 


962 


DISEASES   OF    WOMEN. 


Ovaritis,  chronic,  454. 
Ovulation,  446, 

Palma  plicata,  23. 

Palpation  and  percussion  conjoined,  10,  20. 
Papillary  cysts,  476. 
Paquelin's  cautery,  111. 
Paralysis  of  bladder,  674. 
Parovarian  cysts,  499. 
Patient,  position  of,  11. 
Pavement-celled  epithelioma,  401. 
Pelvic  cellulitis,  555. 
causation,  558. 
illustrative  cases,  569. 
pathology,  556. 
physical  signs,  561. 
symptomatology,  560. 
treatment,  562. 
Pelvic  floor:  anatomy,  112. 

bulbo-cavemosus  muscle,  113. 
coccygeus,  113 
injuries,  112. 
levator-ani  muscle,  112. 
transversus  perinaei  muscle,  112. 
sagging  of,  123. 
sphincter-ani  muscle,  114. 
hsematocele,  596. 
causation,  599. 
illustrative  cases,  603. 
intra-peritoneal,  597. 
pathology,  597. 
physical  signs,  600. 
subperitoneal,  597. 
symptomatology,  599. 
treatment,  601. 
peritonitis,  579. 
causation,  582. 
illustrative  cases,  587. 
pathology,  580. 
symptomatology,  583. 
treatment,  584. 
Percussion,  10. 
Perinaeum,  112. 
anatomy,  112. 

ischio-perineal  ligament,  114. 
bulbo-cavernosus  muscle,  113. 
levator-ani  muscle,  112. 
sphincter-ani  muscle,  114. 
transversus-perinsei  muscle,  112. 
functions,  114. 
injuries,  115. 
causation,  126. 


Pei'inaeum  injuries,  diagnosis,  124, 

illustrative  cases,  144.  , 

symptomatology,  125. 
Perineorrhaphy,  128. 
primary  operation,  128. 

general  considerations,  128. 
Peaslee's  needle,  129. 
silk  sutures,  129,  135. 
silver  wire,  129,  135. 
catheter,  137. 
conditions     necessary     for     healing    of 

wounds,  131. 
conditions    unfavorable   for   healing    of 

wound,  132. 
description  of   operation  for  rupture  in 
first  degree,  137. 
denudation,  137. 
instruments,  138. 
introduction  of  sutures,  140. 
method,  138. 
dressings,  136. 

description  of  operation  for  the  restora- 
tion of  sphincter-ani  muscle  and  peri- 
naeum, 147. 
denudation,  147. 
introduction  of  sutures,  148. 
illustrative  cases,  149. 
description  of   operation  for  restoration 
of  pelvic  floor  in  subcutaneous  lacer- 
ation between  the  vagina   and   rec- 
tum, 155. 
denudation,  155. 
introduction  of  sutures,  155. 
Peri-salpingitis,  548. 
Pessaries : 
abuse  of,  334. 
adaptation  of,  317. 
Albert  Smith's,  317. 
cup,  badly  adjusted,  339. 
Cutter's,  300, 
glass  globe,  298. 
Graily  Hewett's,  86. 
lever  action  of,  321,  322. 
Peaslee's,  297. 

stepi  injuring  cervix  uteri,  334. 
injuring  body  of  uterus,  336. 
Skene's,  for  prolapsus  of  bladder,  667. 
Thomas's  anteflexion,  68. 
Physical  signs  of  disease,  7. 
Physiology  of  ovary,  438. 
Premature  menopause,  427. 
Preparation  of  silk  sutures,  140. 


IFDEX. 


963 


Preputium,  VV. 
Probe,  uterine,  14. 
Probing  uterus,  16. 
Process  of  vivifying  tissues,  14*7. 
Prolapsus  of  mucous  membrane  of  rectum, 
120. 
of  ovary,  468. 

causation,  471. 

physical  signs,  470. 

prognosis,  470. 

symptomatology,  469. 

treatment,  471. 
or  inversion  of  the  urethral  mucous  mem- 
brane, 866. 
result   of   degeneration   of    supports   of 

uterus,  289. 
uteri,  287. 

first  degree,  287. 

second  degree,  287. 

third  degree,  287. 

treatment,  295. 
Protection  of  perineal  wound,  136. 
Pruritus  of  vulva,  94. 

pathology,  94. 

physical  signs,  94. 

symptomatology,  94. 

treatment,  95. 
Pseudo-hermaphroditism,  82. 
Pudendal  hsematocele,  89. 

causation,  90. 

diagnosis,  90. 

illustrative  cases,  91. 

physical  signs,  89. 

symptomatology,  89. 

treatment,  90. 
Pudendum,  76. 

anatomy,  76. 

development,  81. 

diseases,  84. 
Pyosalpinx,  548. 

Rectitis,  400. 
Rectum,  82. 

digital  touch  by,  10. 

examination  of  pelvic  organs  through,  9. 
Recurrent  fibroids,  419. 
Removal  of  uterine  appendages,  509. 

of  coccyx,  170. 

of  sutures,  145. 
Repositors  : 
Aveling's. 
Byrne's. 


Repositors  :  De  Paul's. 

White's. 
Reproduction,  history  of,  7. 
Results  of  surgical  treatment  of  laceration 

of  cervix  uteri,  258. 
Retroflexion  of  the  uterus,  328. 

causation,  330. 

degrees,  328. 

pathology,  328. 

physical  signs,  329. 

prognosis,  330. 

symptomatology,  328. 

treatment,  331. 
Retroversion  of  uterus,  304. 

treated  by  pessaries,  312. 
Rheostat,  374. 
Rigid  perinseum,  125. 

Rigidity  of  muscles  of  pelvic  floor  from  in- 
flammatory sclerosis,  161. 
Round  ligaments,  282. 
Rudimentary  uterus,  35. 
Rupture  of  bladder,  793. 

causation,  796. 

complete,  793. 

incomplete,  793. 

pathology,  793. 

prognosis,  795.  ' 

symptomatology,  794. 

treatment,  796. 
and  perforation  of  ovarian  cysts,  485. 

Sagging  of  the  pelvic  floor,  123. 
Salpingitis,  548. 

acute,  548. 

causation,  550. 

chronic,  548. 

illustrative  cases,  552, 

pathology,  548. 

physical  signs,  549. 

prognosis,  550. 

symptomatology,  549. 

treatment,  550. 
Sarcoma  of  uterus,  419. 

diagnosis,  419. 

etiology,  419. 

fibroplastic  tumors,  419, 

pathology,  419. 

prognosis,  419. 

physical  signs,  419. 

recurrent  fibroids,  419. 

symptomatology,  419. 

treatment,  419. 


004: 


DISEASES   OF  WOMEN. 


Scar  in  vaginal  wall  from  labor,  263. 
Scar  tissue,  120. 

producing  stenosis  of  vagina,  262. 
caused  by  forceps,  265. 
by  treatment,  264. 
Scirrhus,  399. 
Scissors  for  removing  sutures,  145. 

hawk-bill,  249. 
Sclerosis  of  uterus,  220. 
causation,  222. 
illustrative  eases,  223. 
pathology,  220. 
prognosis,  222. 
physical  signs,  222. 
symptomatology,  221. 
treatment,  223. 
of  cervix  uteri,  223. 

following  puerperal  metritis,  224. 
resulting   from  endometritis  and  gen- 
eral congestion,  226. 
Sebaceous  glands,  'ZS. 
Secondary  haemorrhage,  134. 
Septum,  perpetuation  of,  100. 
Sexual  organs,  development  of,  22. 
Silk  sutures,  preparation  of,  140. 
Silver  wire,  129. 
Simon's  method,  9. 

scoop,  412. 
Simple  cyst,  4*74. 
Sims's  vaginal  dilator,  105. 

sponge-holder,  898. 
Skene's  glands,  614. 
Soft  fibroma,  3S1. 
Sounds,  uterine,  14. 
Jenks's,  14. 
Sims's,  14. 
Simpson's,  14. 
Skene's,  14. 
Spasmodic  muscular  contraction,  125. 
Speculum:  Cusco's,  11. 
movements  of,  13. 
Sims's,  11. 
Sphincter  vagina,  121. 
Sponge-holders:  Sims's,  898. 
Stricture :  at  junction  of  urethra  and  blad- 
der, 870. 
of  urethra,  868. 
Subcutaneous  separation  of  muscles  of  pel- 
vic floor,  117. 
Subinvolution  of  uterus  after   parturition, 
214,  217. 

causation,  215. 


Subinvolution  of  uterus  after  parturition : 

illustrative  cases,  217. 

pathology,  215. 

physical  signs,  215. 

prognosis,  215. 

symptomatology,  215. 

treatment,  216. 
Superinvolution  of  uterus,  217. 
Supernumerary  ovaries,  453. 
Suppurating  ovarian  cysts,  543. 
Sutures,  135. 

braided  silk,  135. 

catgut,  135. 

introduction  of,  898. 

prepared  silk,  135. 

silver  wire,  135. 

twisted  silk,  135. 

tying  of,  898. 
Syphilitic  ulcerations,  406. 
Syphilis,  84. 
Systems,  5. 

muscular,  5. 

nervous,  5. 

nutritive,  5. 

sexual,  5. 

Taxis,  274. 

Tenaculum,  Sims's,  898, 
Tents : 

compressed  sponge,  17. 

sea-tangle,  17. 

tupelo,  17. 
Tissue  forceps,  138. 
Torsion,  134. 
Touch,  examination  by,  8 
Tubercle  of  bladder,  811. 
of  Fallopian  tubes,  551. 
Tubes,  Fallopian,  22. 
Tubo-ovariotomy,  509. 

UncompUcated  vulvitis,  84. 
Unilateral  laceration,  285. 
Urethra,  82. 

anatomy  of,  613. 

development,  609. 

dilatation,  9. 

fistula,  914. 
Urinary  organs,  diseases  of,  609. 
Uro-genital  sinus,  82. 
Use  of  catheter,  137. 
[  Uterus,  30. 
1  absence  of,  25. 


INDEX. 


965 


CJterus,  at  puberty,  25. 
bicornis,  25. 
bifundalis  unicollis,  25. 
bipartis,  25. 

bleeding  disease  of,  356, 
development  of,  22. 
dislocations  of,  2*79. 
displacements  of,  286. 
anteversion,  286. 
prolapsus,  286. 
retroversion,  286. 
restoration,  295. 
double,  28. 
duplex,  25. 
excision  of,  415. 
functions  of,  1Y5. 
hypertrophy  of,  30. 
infantile,  23. 
malformation  of,  25. 
mature,  24. 

middle  or  muscular  walls  of,  ITS. 
probing  of,  16. 
retroversion  of,  328. 
rudimentary,  25. 
unicornis,  25. 
Uterine  appendages,  509. 
dilator,  17,  69. 
electrode,  376. 
fibro-cysts,  500. 
fibroids,  497. 
pregnancy,  359. 
probe,  14. 
sound,  14. 

Vagina:  cysts  of,  109, 

development,  22. 

double,  28. 
Vaginal  dilator,  Sims's,  105. 
enterocele,  92. 

causation,  92. 

diagnosis,  92. 

treatment,  93. 
Vaginismus,  109. 
Vaginitis,  105. 

acute,  105. 

catarrhal,  106. 

causation,  107. 

chronic,  105. 

diphtheritic,  105. 

erysipelatous,  105. 

erythematous,  105. 

exudative,  106. 


Vaginitis,  gonorrhoeal,  105. 
idiopathic,  105. 
pathology,  105. 
physical  signs,  107. 
prognosis,  107. 
purulent,  106. 
secondary,  105. 
subacute,  106. 
symptomatology,  106. 
treatment,  107. 
Varicose  veins  of  vulva,  87. 
causation,  87. 
physical  signs,  87. 
symptomatology,  87. 
treatment,  87. 
Vesical  and  urethral  fistulse,  892. 
causation,  894. 
classification,  892. 
urethro-vaginal,  892. 
utcro-vaginal,  892. 
vesico-vaginal,  892. 
complications,  894. 
illustrative  cases,  901. 
physical  signs,  893. 
prognosis,  894. 
symptomatology,  893. 
treatment,  895. 

after  treatment,  901. 
operation,  896. 

Emmet's  needles,  899. 
introduction  of  sutures,  898. 
paring  the  edges  of  fistula,  897. 
Sims's  sponge-holder,  898. 
Sims's  tenaculum,  897. 
preparatory  treatment  of,  895. 
Vesico-rectal  examination,  20. 

touch,  20. 
Vesico-urethral  fissure,  829. 
Vesico-uterine  fistula,  916. 
diagnosis,  916. 
illustrative  cases,  917. 
treatment,  916. 
Vesico-vaginal  examination,  10. 
fistula,  400,  896,  901. 

complicated,  902. 
touch,  20. 
Vestibule,  77,  82. 
Virgin  uterus,  24. 
Vulva,  complete  atresia  of,  82. 
Vulvitis,  84. 

causation,  84. 
diagnosis,  85. 


966 


DISEASES   OF   WOMEN. 


Vulvitis,  due  to  cancer  of  uterus,  84. 
due  to  vaginitis,  84. 
erythematous,  84. 
follicular,  84. 
gonorrhceal,  84. 
physical  signs,  85. 
primary,  84. 
purulent,  84. 
secondary,  84. 
syphilitic,  84. 


Vulvitis,  symptomatology,  85. 
treatment,  85. 

Water,  ice,  or  cold,  use  of,  134. 
Wounds  of  pudendum,  87. 
contused,  89. 

incised  and  punctured,  85. 
causation,  85. 
symptomatology,  85. 
treatment,  85. 


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GROSS  (SAMUEL  W.).  A  Practical  Treatise  on  Tumors  of  the  Mammary 
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GUTMANN  (EDWARD).  The  Watering-Places  and  Mineral  Springs  of  Ger- 
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GYNECOLOGICAL  TRANSACTIONS.     8vo.     Cloth,  per  volume,  $5.00. 

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Vol.     IX.  Being  the  Proceedings  of  the  Ninth  Annual  Meeting  of  the 

American  Gynaecological  Society,  held  in  Chicago,  Septem 

ber  30,  and  October  1  and  2,  1884. 
Vol.       X.  Being  the  Proceedings  of  the  Tenth  Annual  Meeting  of  the 

American  Gyn93cological  Society,'  held  in  Washington,  D.  C. 

September  22,  23,  and  24,  1885. 


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Anieiican  (lynjccoloj^ical  Society,  held  in  New  York,  Tues- 
day, Wednesday,  and  Thursday,  September  1:3,  M,  and  15, 
1887. 

HAMMOND  (W.  A.).  A  Treatise  on  Disejises  of  the  Nervous  System.  Kiclifh 
edition,  rewritten,  enlarged,  and  improved.    8vo.    Cloth,  $5.00;  sheep,  $(». 00. 

HAMMOND  (W.  A.).  A  Treatise  on  Insanity,  in  its  Medical  Kelations.  8vo. 
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HAMMOND  (W.  A.).  Clinical  Lectures  on  Diseases  of  the  Nervous  System. 
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HARVEY  (A.).     First  Lines  of  Therapeutics.     12mo.     Cloth,  $1.50. 

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HOWE  (JOSEPH  W.).  Emergencies,  and  how  to  treat  them.  Fourth  edition, 
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HOWE  (JOSEPH  W.).  The  Breath,  and  the  Diseases  which  give  it  a  Fetid 
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HUXLEY  (T.  H.).  The  Anatomy  of  Vertebrated  Animals.  Illustrated.  12mo. 
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KEYES  (E.  L.).  The  Tonic  Treatment  of  Syphilis,  including  Local  Treatment 
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LUYS  (J.).  The  Brain  and  its  Functions.  With  Illustrations.  12ino.  Clotli, 
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MARKOE  (T.  M.).  A  Treatise  on  Diseases  of  the  Bones.  Willi  Illustrations 
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